20645 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'en Identification I PERMIT NO.
B.fiding Address: 1 ✓ 1v c On ). 1 QS1 V'� 20645
wnersone: A A
H'� L p X50 41 9961161 CITY OPCUPERTINOBUILDINGDIVISION
Cmntracmr.Name: Lie.No: APPLICATION /PERMIT
0
ww6 , BUILDING-F].ECTRICALPLUMBING-MEC LAICAL CATEGORY CONTROL
Architect/Englmer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address, ( PERMITISSUANCE (r�t '(Jl ❑
PLUMB Mt�ji
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commnc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of Dlvbion3ofthe Businenand PmfesslonsCode,and my PANELS
licenselslnfulformanddfM.
License Clam LILY
Dace Contracfio UP TO 200 ANIPSNEl�J l.lJps-suss,)
ARCHITECTS DECLARATION 201-1000AMP5
QZ I understand my plans shag be used as public records. OVER1000AMP5 SQ.FT.FLOOR AREA E/SQ.FT.
O
Licensed Pro(easloal SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MI.SC
m
71o„ y I hereby affirthatlamexemptfrond the Contractor's License Law for the
02f.�
following....(Sectlmn 70315,Buslnenand Profession.Code:Any city or hMP.METFRORPOLEINST.
countywhich mquims a permit to mmtact,Oteg impmve,de=16h,or mpalr
anystructure pdorto its Issuance,else requtmsthe appllantfor such permit to POWER DEVICES
Ufile a signed statement that he b ficensed pursuant to the provisions of the
3a Contractor's Licereelaw(Chapter9(commencingwith Section7000)cf Divl- SI4rM ING IDOL ELECTRIC VALUATION
O sion3ofthe Businessand ProfessionsCode)orthat he is exempttherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by my '1
�o pphantforapermitsubjectstheapplicanttoacivilpealtyofnotmordthan '�7�TiE s TCF FS S,OD — L d00�.
a'vndred dollns(5500). NEW RESIDENTIA'EL — .FT. STORIES TYI'ECONSIRICTION'
I as owner of the property,or my employees with wages as their sole
k7a peosation,will dothe work andthestructure is not intended or offered for \ j
S ❑ le(Sec.7044,Rust.and Profesviov Code:The Cmdramrs Lt..Law
does not apply to an owner of property who builds or improves thereon,and a OCC.GROfJP RES.UNITS
whodaeasuchworkhimself orthrough hbownemployees,provided thatsuch
Improvements are not intended oroffered forsale.If,however,thebuildirq or U yI
Improvement baold withinoneyearofcornpleiomthemwner-builderwillitave
m,4urdenofproving that he did net bund or improve forpurposeofmin.). QTY. PLUMBING PERMIT FEE FLOOD 2IONF APN
U I,as owner of the property,am exclusively contracting with licensed ro1 ppD IySUANCE 1't
contractors to nstruct the project(Sec.7044,Business and I'm eselms Code:
The Contractor's License Taw don not apply to an owner of property who
Wilda or Improves thereon,and who contracts for such ptojeeta with a AI.TFR'DRAIN k VENT-WATER CEA)
ctrador(a)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B h P C for this reasonOUTSIDE FEES
` DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date 1 Z RECEIT N
WORKMAN COMPENSATION DECLARATION FDCURFS PER TRAPrel SCHOOLTAX RFLEII'CN
01 hereby affirm that I have a certificate of convent to self-Insure,ora V
3800riLbrdWorken Coopers.d..Insurance oraceABW copy thadef(Sce. GAS FA.SYSTEM-1 INCA OUTLETS ^L`OV PARK FEE Y_ N_
RECEIPT
I
Policy N
Com GAS F.A.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
any _
�
Certlfled copy Is herebyfurnished.
inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE '
the
❑Certified copy V TIM withh the city
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCeI t#
(Thissedlon need net be completed if the permit Is forma,hundred dollars
(Slm)orleas.) WATER FTFATFR W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the Performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATIR SYSTEM/TREATING
Workcis Compensation Lawsof Calfomla.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recel t#
Z O NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you
should become subject to the Workers'Compensation provhlons of the Labor TOTAL:
KN Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
Waseemed revoked.
O CONSTRUCTION LENDING AGENCY SEISMIC FEE a
1 I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE C11
Z
an.of the work for which this permit la icsued(Sec.3097,Civ.C.) Q PLUMBING FEE C 00
(� O lenders No
LL I— Lender.Addre.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Iccrtlfythat l have read this application and statethatthe above information
O W lam IywBit II city and county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
} a ngmb illm,ronst Ion,and hereby authorise representatives of this
N ty tor
nterupon theaW mentioned property for Wpection purposes. ALTER OR ADD TO MECH.
? (We)agree to save emnl d keep harmless the City of Cupertino Date Receipt#
V afien billties,' menp, s dezpensnwh may in anywayacede AIR HANDLING IIN7T(4010,000 CFM) SUBTOTAL:
ains in dese u the granting is perm
_ NR HANDLING UNIT(OVER I0,000CFMI CONSTRUCTION TAX
lfgraolA c t ordmctor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A]ARDOUS MATERIALS DISCLOSURE
Will the karst or future building occupant store or handle hazardous HEATING UNIT(TO t 00,ODO BET) Date Recel t# _
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ��j�
4lealthand Safety Code Secion25532(a)? HEATING UNIT(OVER IWM BTU) TOTAL: � 4 Jv
❑ Y. f]No
Will the applicant or future building occupant use egolpment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
PCaliforela
ns ement District? BOILER-COMP UHPOR 100,IXO BTU) 10 Abp.
nNoad theh Id..materials requirements underChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
ia I lealth SafetyCode,Section 25505,25533 and 25534.1 �,11 UZ 199-that l! bulldinotarren yhavea tenant,that it is my NEW RESIDENTIAL MECli. SQ.FT. Vityt Alty the aolzfthe irement.wh ich most be metce ole Ce 1 cofOnuput rf dagent J Data Iggppp BY:
FAY-+•t
TOTAL:
OFFICE COPY