22905 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PI- TNO.
BuBding Address:
0_33,�10 \11A- 6!VL22905
wnare crus: � J one: p
M41 e 14ieS &i/a2(.SO �7 77ctc7 CITY OF CUPERTIINO-BUILDING DIVISION
c°n acter'aNam: Llc.No: APPLICATION / PERMIT l J
f/ 6eQ,1701 BUILDING-ELECTRICAL PLUMBINGMECHAMCAL CATEGORY CONTROL
Architect/Enguseen Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreu: PFRMITISSUANCE ❑ ❑ �It�—/-a�
LICENSED CONTRACTOR'S DECLARATION pppppNC6RF9DEMTAL �-�s
I hereby a((Irmthat Iamgm3ofunder p and ofChapter9(w,andm Ipg��j;
Ingwlth I.fun 7000)of doff- 3o(the BudnemandlkolesslonsCade,and my
Jim b I.
nM fe and e((M. PANELS
Llconw Class_ LIc.Y 7
CHITEmr + Lba„�s�+�
ARCHITECPSDE ATI 811-11XX)AM 1 Aft
_ V , �/
reO ZCp Iunderetand my pore eM1aB be used sspubgerecoNa OVER 1000 AMPS SQ.FT.FLOOR ARCA S/SQ.FT.
oU Licensed Pro(emle.l SIGNSELECTRICAL
«<�< OWNER-BUILDER DECLARATION SPECIAL CEtCUIT/M15C
zH G Iherebyaffirm that l am exempt from the Contractor's License Law for the
following remora.(Section 7031.5,Business and Professions Code:Any city or
O O EIMIOWERDEVICES
ETLR ORPOLE INST.
�
county which requires permit rocoaruct,alter,Improve,demoWM1,orrepair
ggg any structure prior to its Issuance,also requires the applicant for each permit tofile a signed statement that he b licensed pursuant to the previsions of theContactor.License 14.(Chapter9(commenctng with Section 7000)°(Divi- VALUATION
Hti don3o(the Business and Profmlons,Code)orthat he ls exempt therefroma odNG POOL ELECTRICOu theW"L,tar the alleged exemption. AnyviolationofSecion703L5byanySSWITCHESF1XfI11tE5'SSSttt?111ccc appBcsnl lora permit subjectathe applicant to a civil perulty of not more thanfive hundred dollars($500).'9.+' ❑I,as owner ofthe property,or my employeeswith wagesastheirsokID LIM— STORIES TYPE CONSTRUCTION
mmpensation,Mll doth¢work endthestm=m ls net Intended or offered for
5.90 Is(&c 7040 Business and Protonic.Code:The Contract.(.License law
$$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who doeseuchwork M1imelforthrough Meownemployees,provided Ihatsuch
Improvements are not Intended proffered forule.If,however,the building or DATE O A
Improvement beuid within oneyearofcomplertion,theowner-Wfiderwill have
t1den of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOODZDNE � APN
tvae owner of the property,am exclusively contracting with Ilemsed PERMIT 155UANCE
contradas to rorstmct the project(Sec.70K Business and Professions Code:
The Contractor'.License taw does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improve thereon,and who contracts, for such ptnjnms with a
mFEE SUMMARY
�jpactor(s) impursuantled punt t°theContractor's License Law. BACK FLOW PROTGGT.DEVICE
L i I am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND, OUTSIDI,FEES
SANITARY Y N
Owner Date , RECEIPT#
C31
heOd
WORIANCOMPENSCHOOL SATIONDECLARATION FIX.[l1RF$PER TRAP Y N_
reby affirm that I have a certificate of consent to self-Insure,or• RECEIPT Y
3800,L.b C.)eofWorkea'Compe.atlonl.unnceor•certified wpytFemaf(Sw. CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polisa
Polity Y RECEIPT N
Com an GAS EA,SYSTEM-OVER4(EA)
[P Y BUILDING DIVISION FEES
Certified copy ls herebyfurnished.the city GREASE/INDUSTRL WA5 IT INTERCEPTOR PLANCHECKFEE
Certified copy I.filed with the city Lpecilon division.
CERTIFICATE OF OMPTION FROM WOR KERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARYSIORM EA 200Ff Date Recei t#
(TFTs action need rad bemmpleted tithe permit Is(orooe hundred dollar
(5100)°`less') WATER HEATER W/VENT/Fd.EGTA ENERGY FEE Y N
I certify that In the performance.f the work for which this permit is Issued, —
I shall not employ any person In any runner w m to become sub'aajj to the WATCR SYSTQd/TREAT'INC
Workers'Com encatlenlawsof Cahfa, Date_ ,L PAID
NEW RESIDENTIAL PLM°.
0 Z Applicant _pSQ�.. Date Reeei t#
Z 0 NOTICETO APPLICAM:IL akar making this ertlflale of Cxemptbn,you
~
should become subject to the W°rkon'Compematl°n provisions of the Labor TOTAL:to Code,you must forthwith comply with such provlslpns orthls permit shall be
tY > deemed revoked. '
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. Ihembya(Mmthat there is a construction lendi^gagency,forlhe perform Tout: ELECTRIC FEE
D Z once ofthe worktorwhlchthls permit is huued(Sec.3097,CIv.C.)
U O Lender's Name PLUMBING FEE
LL F Lceder'.Addm.. QTY. MECHANICAL PERMIT F'GE MECHANICAL FEE
OW 1mAilythat I have read this appliation.ed AMethatthe above Information
1 lscorree.I agree to comply with all city and county ordinance and date laws PERMIT ISSUANCE —�� FEES PAID:
�. relating to building coa.ction,and hereby authorize representatives of this
N
I'- Z city to enter upon the above-mentioned property for Inspection purposes. ALMORADDTOMECH.
z (we)agreo save,Indemnlly an d kre harmless the City of Cupertino Date Receipl#
agaiallablli a judgmenta,wdeandex seswhlchmayinanywayaccrue AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
agal.tuid I In cons bnceofthe tingofth permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slg.. ° lant/Contractor Data EXHAU5THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA ALS DISCLOSURE
Will theappllant orfuture building occupant stem or handle hazardous HEATING UMT(TO 100,000 BTU) Dale RCCeI I#
material a.defined by the Cupertino Municipal Code,Chapter 9.17,and the
liealthand Safey Cod ion ZS532(a)7 HEATING UNIT(OVER 100,000 HIM TOTAL.
MjJ
❑Yes o
WIll the appli.^t)r core building ocmpanl use equipment w devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air r A i D
Quality Ma.gemont DistrictBOILER-COMP ptm OR 100,000 BTU)
4 YesNo
have read the h see materials requlrementsunderChapler6.95 of BOE,ER-COMP(OVER 100,(X10 IT"the Calif°mlallealt &Safety Code,Sectio.25505,75533 and 25534.1 OCT 25 1991
understand that If the building does not rrenlly haveatanaot,th.titi,.y NEWRES)DENTIALMECH. SQ.FTr
respo.Ibin °not ifytheocmpantofl requiremenlswhlch.utbemet
prior to lss a ce ofe rtl0cate of Oc anry. CITY�OsaF�C�U?Er11IlvU
TOTAL: SUE
Owner or sed agent Date_S SDBYrG1�%`��`
OFFICE COPY