20711 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 1111CWT NO.
Building Address: 2 0 7 1 1
Owner 9 Name. A G I
—S EtlO`/I Q'46'897a CITY OF CUPERTINO-BUILDING DIVISION
Cmurattn%raNam, / ELIe.N.: APPLICATION if PERMIT
M. G. \ LL CsavSy(JG>f S-`z BUILDINGELECTIUCAf UJMBING-MECHAMCAL CATEGORY CONTROLM
Archlled/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO�-y,
Addre' 10244—, Av(( PERMITISSUANCE — j')' 00
BLDG ELECI PLUMB ml�ti
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under p.Eimaof Chapter9(rommene. APPLIANCFSRES)DENTIAL JOB DESCRIPTION
'ngwithScatton7000)ofDlvlelon3rDhe B..lnessand Profeval.aCode,and my s� `
���
Ilmnaelslnfull JJJJJJggqqqq eandeffet. -��FF PANELS
Lice LIc.R yJ2y� FN—c—
Date ys UP TO 200AMpq
Cormier. - �- 74,a T.�V p1-1000 AMPS
ARCHITECTS DECLARATION OVER IBM AMPS SQ.FE.FLOOR AREA E/SQ.FT.
�! I understand my plans shall be used as public records. as
O
�j Licensed Professmrai SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCIiCUIT/M
1„ 7 Ihereby.M.thatI.m xemptfromthe Comrad.e.Lice..Ua forths
Z 9 following mean.(Section 7031.5,Buslneasand Predated...Cods:Anydtyor ypArp OR IL
�L�'j rountywhiOrtnuie aper tW=vtmd,alter,improve,demo h,orrepalr
�E anystmmmpIt
r rtolUt ance,aL requimtheappbontforsuchper tto POWER CFS
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's (ChapterLicense Law 9(comerencin with Section 7000)of Divi. VALUATION
sion 3 ofthe Business and Profeions Code)or that he is exempt therefrom and NG L TRIC ION
y� the basis for the alleged exemption. Any violation of Section 70315 by anyO 0[Tlti ps ! v 1t1 Al O p B a
ym applicant fora permit subjectsthe applicanttoa civil penalty of not rrorethan J V V 00
c� five hundred dollrs(A50W. NEW RFS AL ELECT� FT.j ❑1,as owner of the property,or my employees with wages as their sok SEO FS TYPE CONSTRUCTION
C compensation,will do the work,and the structure is not intended or offered for
5 O sok(Sec apply to alnowandf property Cade:The lds orimperms hire eLaw
don not torn owner ofpropertywhonemorimproovided that such V and OCC.GROUP RES.UNITS
who doessuch are nothimselfdedcrough his men e.If,h however,
the building
ilding or
'unprovementba ldwinlenoneoarofcreoleic ]t hower.Wfldbu iil gve OTAL:
t proveroem proving
tht he did of build
Improve
fo purpose
t ben ofproving that he did not build or improve(or purpose ofsaleJ. QTY. UM LNG PERMIT FEE EIAOD ZONE APN
[_I L as owner of the property,am exclusively contracting with Licensed PpR,MR ANC
contradors to comtmct the project(Sec.7044,Business and Profession Code:
The Contractors License Law does not apply to an owner of property who
Wilds or Improve thereon,and who contracts for such projects with a ALTgAYRAINk VENT-WATER(EM
ctor(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B h P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Weser Data r RECE'TN
�• WORKMAN COMPENSATION DECLARATION pp(.EUgES PER TRAP SCHOOL TAX Y_ N_
I/Ia hereby affirm that I have a certiflute of consent to self-Insure,or �'(7 U RFAE N N
ceninmte of Workers Compareation l2revrance oracenRkd copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Iab C.) .b2O�.J215 RECEIPT
ICCC'tti���g❑❑❑N V.1 GAS EA.SYSTEM-0VER4(EA) BUI LDI NO DI VISION FEES
F1 rdtfied ropy 6 heed with the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
--�s nlfled copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCmi t#
(This section need net be completed B the permit is for one hundred dollars
($IM)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N—
I cxr ifythat In the performance of the work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Werke&Cempenaatmn laws of C.aIfomia. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFE. Date Reed t#!
ZO
NOTICETO APPLICANT:ILaher makmgthIs CcrtIfloteof Exemptbn•you
should become subject to the Workers'Comperwtlon provision of the Labor TOTAL:
CCN CWe,you must forthwith comply with such provisions orchis permit shall be 13VILDING FEEypp
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE a
Il I.fthyaffirmtWhicht6par truct.ed(Slc. ag7,Cio. .) perform ELECTRIC FEE
7 Z annder'n work for whkhthb permitLS Issued(Sec.3097,CIv.CJ - TOTAL:
O O Lenders Name PLUMBING FEE QQ
LL H ).ender.Address QV I MECHANICAL PERMIT FEE MECHANICAL FEE
OW I ceNfythatl have read thisapplicationand statethat theabove Information
1 rorret.Iagreeto comply with allcityand countyordinanm and state laws i PERMIT ISSUANCE (�,b0 FEES PAID:
>- 0. to building conamadlon,and hereby authorize representatives of this
N City to enter u Pon the
.bove-mentioned property for l"pedlen purposes. ALTERCRADDTOMECH.
Z (We)agree to save'
Inde=%an d keep ha m the City of Cupertino Dale RCeejplll
V agalnsth.bllltles,Ndgmenta,coslsand ex s¢ lehmxyina wayaccrue AIRFIANDLINGEINITTT010,"CEM) SUBTOTAL: _
against sold City In conseque oche tl of this permit.
7 , AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
�Wgfimmol Appllcant ontrador Dat IXHAl15'T HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
to enter
orfuture building ompant.toreor handle hazardous HEATING UNIT(TO100,000BTU) Date ReceI t#
material as defioed by the Cupertino Municipal Code,Chapter 9.12 and the -
lkallhandSafetyCode ion2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
0 Yes e2No
Will the applicant or futurebuilding occupant use equipment ordevices VFNEILATION FAN(SINGLE RESID) ISSJ,I(1�I�ATE
which emit hazardous air contambuma as defined by the Bay Arca Air ����a/
Quality Management Dist 7 BOILER-COMPOHPORIW,00l1BTU)
I�Y¢ No rr11
,.4havc read the ous materlals rcqulrements under Chapter 6.95 of BOILER-COMP(OVERIDg000 BN)-the
N)
the California Health A SafetyCade,Sections 75505,25533 and 25511. 1 1 qj� j
understsedthatifthe building don not cumly have a tenant,that it is my NEW RFSIDENRAL MECFL SQ.FT.
r¢porsibilltymndify the cepa est (t rcqulrcments who mus carat cjW Cupertino
p' o nto ofd teo anry.
ror auth6tidenipect I to �-t/Y ISSIIEDB —
j.
TOTAL:
OFFICE COPY