23099 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT, PEN ONLY
.r. Buildin Protect identification , - PERMITNO.^
B.Id,ngA#Iresa- 23099
OwFae Sb� �wsg Utz-;
nere aone: AppLicAlION 5ijbioinAL DAIL
DI
CITY OF CUPERTINO-BUILNG DIVISION'
cors noraName: uc.No:. APPLICATION /PERMIT .
i -
BUILDING-1I.1:CTRICALPLUMBINC-MECHANICAL CATEGORY ONTROLN
Arcltxt/Engt r. Llc.No s_C
22 � ......
0 .tys ct- ''.'FEE "j` .'•,tit BUILDING!ERMIT,INFOPs'•
Address - e PERhRTISSUANCEI ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc- APPLIANCES-RESIDENTIAL ' JOB DFSCE1111ION
ngw,th5 ton MW)of Dlv,s,on3of[he Busimsand Profeny nsCodgand my - - - -
licenselsin(ullf rce end dlect. AL/Y� C7/ o PANELS 046L)%L�'.
S.IcenseCWm' "Lie.p TFl7 �...CCC111 P„J V
Date Conhact7 _ -
ARCH ITbeused DECLARATION - OVSR00 AMPS
µq��CO ]understand my plans shag be used mpubecremrds OVER 1000 AMPS SQ,]7.I•LOOR AREA $/�.FT.
.E pj Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
I heroby affsmnthat I am exempt from the Contractors License Law forthe
following reason.(Section 7MI.5,Business and Professions Code:Any city or TEMP.ME[ER ORPOLEINST.
�G �qq�yy countywh,chrequiresaper ttommtmct,altegimpmwdemolish,ormpair
q :n anystmcture prlorto lfa Lssuan<e,aisomqulreathe applicantf°r such permitto POWER DEVICES
67 V file a signed statement that he Is licensed pursuant to the provisions of the - '
Contractors License Law(Chapter 9(commencing with Section 7000)of Div,- SWIMMING POOL ELECTRIC VALUA 2%V
sem3 ofthe Business and Pmfesselons Code)orthatt hole exem therefromand M -
E~ 0 5 the bash for the alleged exemption. Any violation of Section 70315 by any. OUTLETSSWITCHES-FIXTUFFS
applicant fora permit subjectathe applicant to a civil penalty a not more than
live hun s owner
the
NEW RESIDENTIAL ELECTR SQ.pT. STORIES. TYPE CONSTRUCTION ^
❑I,as owner of the property,or my employees with wages r their sale
ompeec.70 n,Buldotheworkandions Code:The
Intended orofferedfor
Osale(Sec.7614,Business and Professions Code:The Contnactore License Law
does net apply,to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who does suchwork himselforthrough his own employees,provided thatsuch
Improvements are not intended oroffered forsale.If,however,thebu,lding or TOTAL: -
Improvementissoldwithlnoneyearofcompletion,the owner-Imaderwlll have t ,, c- s't•','�� ,rs}'
t rdenof provingthat he did notbuild orimprove forpurpmeofsale.). QTY. {it''.•.,,E &M`BiN&PERMIT•? t. 1'^ E,' FLOOD ZONE APN
"I,as,owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE - -
mntmeWo,to mromot the project(Sec.7654,Business and Professions Code:
The Contra$or's License Gw does not apply to an or of property who -
Wilds or improves thereon,and who mneacb for such projects with a ALTER-DRAIN VENT-WATER(EA)
oq➢F(aetor(s)licensed pursuant to the Contractor's Limme Law. i71�.cC5 z4 ' ,,FEE-SUMMARY, be
(_J I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
al.zl
r—' SANITARY' Y_ N_ -
Owner Data DRAINS FLOOR ROOF,AREA,COND. E RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP Y_ N_
FIE hMSCHODLTAX
ereby aff nn that I have a certificate of consent to self-insure,ora RECEIPT X
certificate of Workson'Compemationlnsurance or a certified copy thereof(Sce. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.)-
RECEIPT q
Policy - GAS EA.SYSTEM-OVER BUILDING DIVISION FEES
Com any ,
Certified copy is hereby furnished. - / s /[ oum wA [ eP PLANCHGCK PEE'
❑Certified copy is filed with the dty inspection division. `I LY7
.' CERTIFICATE OF EXEMPTION FROM WORKERS' G '�� :_ PAID LLL
COMPENSATION INSURANCE
SE -sA Y _ I -Date •Recei tri
.' (Chis section need n°thecompided if the permit bforone hundred dollzrs
I t ($100)orless) WATER HEATER w ECTR ENERGY FEE Y_ N_.
Icertifythat In the performance of thework forwhich this permit is Issued, i _
I shall not employ any person in any nanner so u to became subject to the - -
Workens'Compensation Laws of California. Date - W PAID
`O,tip' Applicant ' NEWRFSIDFNTIALPLMe. SQ.FT. Date Recei t# .
.ZO NOTICE TO APPLICANT:If,after making this Certiflate of Exemption,you .
should became subject to the Workers Compensation provisions of the Labor TOTAL:
I� N Code,you moat forthwith comply with such provls,muorthis permit shallbe BUILDING 'e
W > deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE'
.t1'� Iherebya(fitm thatthere B a construction leadiagegency forthe perform TOTAL: ELECTRIC FEE
'•� 2 ante of the work for which this permit Issued(Sec.3097;C1v.C.I -
V O Lenders Name .��k' P PLUMBING FEE
LL Leaders Address - Q71k. ' 'MEGFIANICAftPERMIT .FEE'{+, MECHANICAL FEE
OI certifythatl have reacithis appliationand statethallhe above Information
W
D. is mrcall cityrct.I agree to comply with all and county ordinances and slate laws PERMITISSUANCE FEES PAID:
} W rciming to building construction,and hereby authorize representatives of this -
F city to enter upon the above-mentioned property for inspection Purposes. ALTERORADDTOMECH.
Date Receipt# 1
(We)agree to save,indemnity and keep harmless the City y Cupertino
V against liabilities,rydgmenb;msts and expenseswhich may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) 'SUBTOTAL:
against said City Inco ce of the grant g of thli permit - _
��'' Aix HANDLING vMT ro lm ic,"CFM) CONSTRUCTION TAX
.. I GC
Signa of Appllant/Cos for to EXFIAIISTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA$� SMATERI .S DISCLOSURE -
IINapplicantorifs rebuilding occupant store or handle hazardous- HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by tli upertino Municipal Code,Chapter 9.12,and the
• Health and Safety Code Section 25532007 - HEATING UNIT(OVER 100,000 BTU) - TOTA
❑Yes h`Ia�Nn - - ,
Will the applicant o rebuilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
}r.P which emit harardous air contaminants as defined by the Bay Area Air - P�•�a
Y Quality Management District?, BOILER-COMP(311POR 100,000 BTU) A Y D,
CYc F/l No
have read the Faysmateriab requlrcments under Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU) Q
the CaliforniaHealth building
Code, utcomctlyh have
and 25534.1 ®EC 16 1991 ® 4
and aliforniaHalth buildingdoes notmns25yhave33andt,that ti..y NEWAGSIDEN77AL MECH.. SQ.FT. - vC
responsibility to notify the occupant of the requirements which must be met -
'PnortuesuanceofaCert ateelocciapancy�. CITi.Y
OF Cupbi I INU
Owner thorired g.m, - Da ISSUED BY
TOTAL:
OFFICE COPY'