20156APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification -
Building Address:
02�o Pii,41� l PrP PRIME
PERMITNO.
20156
wnersonto: one;
RAM l �_RL) alIA
_k�GZr
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING-MECHANICAL
Ccntra_n Na LIc.Nw
CATEGORY
CONTROL I�e�l
I 71
Amhltect/Engineer.
CnR N(. R V LcNo:
QTY ELECTRIC PER FEE
BUILDING PERMIT INFO
Add.r TTI OtL
7i;2&=
rDfuu/�
PE(MITISSUANCE
LICENSED
EDCONTRDECLARATION e
Ihyoen'hat d!underprovisions ofChaptr9(commenc
Ingwithsin7O si=3 rlheBusinessandProfesonsCode,and my
liensIs 1. lull force and efftet.
License Class
MPLIANCFS
JlLOateBJ
FSCRII1�GT�O,JJ N
fzc--
•T\..u.
1J4� (i N {/
PANELS
Dae.Contractor
actor
4RC S DECLARATION
n land a1 e u Rublic re
Licensed Professional u C s2
OWNER -BUILDER DECLARATION
I hereby afflrmthal l am exemptfromthe Contractor's Lkense Law for the
fallowing reason. (Section 7011.5, Business and Professions Code: Any tlty or
county which requires a permit to constmet, after, Impmve, demoWlbmrepair
anystmcturcpdortoilsissuance,alsomquimstheapplicantforsuchpermitto
'file a signed statement that he ls licensed pursuant to the provisions o! the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
slon3 ofthe Business and Pmfe.Jma Code)mth t hels exempttherefromand
the bash for the alleged exemption. Any violation or Section 7011.5 by any
applIcanttora permit subjects the applicant to a civil penalty of not morethan
five hundred dollars (SM.
F11, as owner of the property, or my employees with wages as their sate
compensation, will dothe work and lhestuaturc Is not Intended or offered for
sale (Sec. 7004, Business and Pralenimus Code: The Contractors Lim. law
does not apply to an owner of property who Wilds or Improves thereon and
work himself orlhrough Neown employee,provided <hataah
Improvements arenot Intended proffw
ered fee ole. IL hoevegthe Wilding or
improvement Issold within oneycaro(compleibR the owner-builderwlll have
Xt1�,�rdenof proving that he did nM Wild or improve fee purpose of sale.).
J,.owner of the property, am exclusively contracting with licensed
rat cion to ceredruct the project (Sm 7044, Business and Professions Cede:
The Cantnctera License Law does not apply to an owner of property who-
builds or Improvn thereon, and who connotes for such ptojects with a
o9wacmr(s) Banned pursuant to the Contractors License Law.
LI f am exempt under Sec. B & P C for this reason
IDI -1000
OVER 1000
SQ. FT. FLOOR AREA
` (JIJ
1 .ry
Q 0 �p
5/SQ. FT.
GNS E. AL
5 IAT. MI
pg E INST14k.
DENCFS
NG FOOL EL � C
10 OUTLETSSWiTCHFSE
VALUATION
NEW RESID AL LC SQ.FT.
STORIES
TYPE CONSTRUCTION
^ ,
TOTAL •.
QTY, PLUM ING PERMIT FEE
OCC.CROIR'
RIS. UNITSwhodoessuch
PERMITISSUANC
ALTER -DRAIN& VENT- WATER (W cz
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, GOND.
/ FD(•IVRFS PER TRAP t,eq
f0 Vu
SANITARY Y_ N ,
RECEIPT 0
Owner Data
❑ b WORKMANCOMPENSATIONDECLARATION
I hereof iren that I have a certificate of consent to seR-inure, or a
certificate orWorkerf Compereation Insurance craceatfted copythereof(Sec.
3800, Lab C.)
PolicyM
Sp{ppL TAX Y N
RECER NM
GAS CA.SYSTFM-1 INC.4OUTLETS
PARK FEE V N
REC IPTR
CAS EA. SYSTE.fAVER4(FA)
Cam eny
BUILDING DI VISION FEil9
Certified ropy ls bed with he city
Certified copy I. filed with the city Irupectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCESEWER-SANITARY-SPORM
Thlssection need not be completed if the permit is far om hundred dollars
O1utimfess.) rtlfythat In the performance o(the work for which this permit buM
I ls ,
I shall not employ any person In any manner n s to become ubjed io the
Workers Compensstlonlawsol Gllfomla. Date
OTICE
NE TO
NOTICAPPLICANT: If, ober making thio Certificate of Ezemptian, you
should become subject to the Worken'Compaeation provlsipna of the Labor
Code, you at forthwith comply with such provisions or this pemitahall be
dewed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afOrm hat Is a mmtmctlon Iendingagenry, for the perform-
ance, of the workror which this permit is Issued(Sec. 3097, Civ, C)
a.r. Add as
Iceditythall love rcad<hlsapplicatlonand rtatethattheabove infomuties
lammed. lagreto comply withal) dtyand muntyordlnanms arucl elawa
relating to building maatructlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harrNess the City of Cupertino
against liabilities, Iudgme ta, mete and e a which naytn anywayacoue
g0C saidClty one the tingofthlspermit
aignatumof
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
DatC Rerni ted
��pI��`
'Ll
GREASETRAP
EA. 200Ff.
WATER HEATER W/VFNT/ELECTR
ENERGYFEE Y N_
PAID
Date Rernl IN
3�`
0a(.�
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB, SQ.Ff.
TOTAL:
BUILDING
SEISMIC FEE
•�
1
�/
TOTAL: L)Dx�
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Gp
MECHANICAL FEE
t
^�
r PERMITISSUANCE k")_ On
TEES PAID.
Date RL'CCI t#
ALTER OR ADDTO MECH. 2�CD
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
Plica /Cont Da���
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
1 lealth n Yead Safety CadeiSyylioon 25532(a)7
ill the a ppllont orfutum building occupant use equlprnent or devices
whichemit hazardous air meta Mnants as defined bythe Bay Area At,
Quality Management Dlatrt
Dyes o
have read the hazy ous materials requirements under Chapter&95 of
the California Health & Safely Code, Sectiore 25505, 25533 and 25534. 1
understand that if the building does not currently have a tenant. that It is my
resporutbil notify the.. ftherequirerrentswhich must be met
priors a of Ic o cep Cy.
4-14-9
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 IITU)
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
OTAL:rem
VENTILATION FAN (SINGLE RESID)
DATE
��Q,(�
AUG ��7,jy7
�\y'�'�+z�s
ISSUEDBY-
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,001) BTU)
NEW RESIDENTIAL MECH. 5Q.FT.
OwneroraW orlm agent Date
TOTAL: C7i
OFFICE COPY