20453 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
dding AddreBuildin Project Identification PERMIT NO.
Bua,: 20453
5%
oars ams: one: AL DA 11
CITY OF CUPERTINO-BUILDING DIVISION
p ractoraName: Tc.No; APPLICATION I PERMIT S^�
� BUILDINGELECTMCALPLUMBINCMECHAMCAL CATEGORY CONTAOLN .
Arc ieect/Eng neer. Lie.No:
�QTY ELECTRICPERMIT FEE' BUILDING PERMIT INFO
Address: PERMITISSUANCE 2100 El � It�i' El
CONTRACTOR'S DECLARATION �f
I herebySectio 70 that lemlo.3.f under sB.g ovtdonso(Chapter Ce s,andmc- APPLIANCESRF.SIDENTIAL JOB DESCRIPTION
Inense i Section 7000)of IRW eon3oftheguetnemand Prolemlone Code,and my
license is In futo and effect. PANELS
License Clam_Ile N_�'�` Q'`f""T'r� tat
DaleC�9 a C HrrF or r�4e W J
riJ ARCHITECT ECLAR TION M14000VA _
Lp�0 CO I understand my pbsu shaft be used m public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E ly U Licensed Professional SIGNSELECTRICAL lA
l<«< CLvd OWNER-BUILDER DECLARATIONO�
+n]
Z
I"'BI I herebyalArm that 1 am exempt from the Contractors License Law for the SPECIAL CIRCUIT/MTSG
pp O following reason.(Section 7015,Businessand Pmfemm inCode:Any city or Z F. TEMP.M OR POLE
muntywhichcture rcquirna permne,alsoreuiresthe.reconstruct,alter, pmvgdemolbh,orropstirml
q yy le atsudurc prierto menta that
he ba alaorc d pursuant to the promchperfNt a POWER D S
f5 C Ilia a signed statement that M is licensed pursuant to eta provlsloru of the
Contractors Ltd.Las,(Chapter 9(m.reirgwith Section 7000)ofDivl-
�0� tlon3 ofthe Business and Pro(.kuuCode)orthat he is exempt therefromand SWIMMING
the baste for the alleged exemption. Any violation of Section 7011.5 by any DDTLETS-$007 H ��C17
eppVrant fore perNe aubjeds the applicant tea tivll pevlty afnd more/han
flue hundred dollars he pr). NEW RESIDENTTA EC STORIES TYPECONSTRUCTION
q�.e ❑Laaowner wodothe wpri property,ormy athe mours nwith wagn as lMlysole for C compensation,1.&. 044wRldotheworkaodions;Cdurehe out ConttendN orofferedLw
p sale(Sec.7044,Business and Professions;Cade:The Contractors License Law
docs not apply to an owner of property who Wilda or improve thereon,and OCC.GROUP RIS.UNITS
whodon such work himselforthrough his own employees,provided that such
improvementsarenotlntendedorofferedformle.T(hmmegthe Wlldingor TOT L: ` m '
improvement bsoldwlthln oneyearofcomplelbn,the owner-bullderwill have
t e rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT 'EEG EAOD ZONC nrN
�;as owner of the property,am exclusively Business
with licensed PERMIT ISSUANCE I'-1 co
TheconC.on to constructtheLaw project(Sm
apply t alnem and Professions prop rt Code: 4
The Coor Imprb License n, don who
apply to; f owner d property who ALTER-DRAIN&VENT-WATER(EA)
Wilds a or Improve thereon, and who.rontnct. for such p(ofecte with a
dffIctor(sexempte under Snt to the Contractors License PLaw. BACK FLOW PROTECT.DEVICE FEESUMMARY
1_J I am exempt under Sec B&P C for this reason
�M1 Owner Date DRAINS EA,COND.FLOOR ROOF,ARSANITARY Y_ N
) WORKMAN COMPENSATION DECLARATION r� RFLEB'Tp
❑I hereby of urn that I have a certificate of consent to.elf-Insure,ora ITUTURES.PER TRAP yQ0 `SCHOOLTAX Y_ N_
, .. mn ifirateo(Workers'Comper flonlmumnmmarertif4 mpythereo((Sec. GS-E .SYSTEM-1 C40IIRECEIPT
3800,Lab C. PARK t. N
Y N
po11ry N
Cnm an Tt- ti CAS EA.SYSTEM-OVER DING DFN
Y BUILDING DI VISION FF.ITS
caressed copy hS.+ led witume city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�2lAifl-M ropy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYEA 200FT Date Rs t#
Qhlsunlon need not be completed If the permit bier one hundred dollars ett'P
(4100)or lemJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit is lamed,
I shall not employ any person In any manner so m to become subject to the WATER SYSTCM/TRG7ING
Worker%Compensation Lawaof California. Date PAID .
O Z Applicant NEW RESIDENTIAL PIMB. SQbT. Date Recei t#
Z 0 NOTICETOAPPLICANT:I;after making this Certlflote o/Esemptlon,you
should become subject to the Workers'Compensation provblom o(the Labor TOTAL:
N Code,you=at forthwith comply with such provisions orthla permit shall be
j deemed revoked.
BUING FEE
ILC CONSTRUCTIONLENDINGAGENCY SEISMIC FEE
1 Z Thereby afArm that there b a com uctlon lending agency for the perform- ELECTRIC FEE a4'�
ance of the work for which this permit b Issued(Sec.3097,Civ.C.)
V O lenders Name , PLUMBING FEE W
LL I— Landers Address Q1Y. 'MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl have read thbappReatioeand patethattheabove Information
(1 bmrred.l agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PATI}
N relating to building construction,and hereby sceneries representatives of this
F Z city to enter upon the above-mentioned property,for Inspection purposes. ALTERORADDTOMECH.
(W a to save, s %and keep harmless the City of Cupdthm Date Receipt#
V a tRabl in,judg e,abeband expeaseswhichmayinanywaysecrus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
abut City lnm ence oftbe anting of tnb pe L AIR HANDLING UNIT(OVE410,000CFM) CONSTRUCTION TAX
SI mo AppRrant/Cont do Date ExHAus'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD U ATERIALS DISCLOSURE
Wllltheapplies a or fu uilding occupantstoreor handle hazardous HEATING UNIT HO 100,000 BILB
mDate RCCCI t# _
aterial a a defined by theC rtor,Mu niclpal Code,Chapter 9.l Z and the (}
Iieatth and Safety Cade iyien-4,5532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: v a60
Yea 0 No
ill the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSLANCE DATE
frhich emit harardous air contaminants as defined by the Bay Area Alr - P/ER^)
.� Qiality Ma wm
geent Dlstrl BOILER-COMP OHP OR 100,000 BTU) AOA./
4 Yn o
theChaveread the haze ousmateriab requ irements under Cha pter 6.95 of BOILER-COMP(OVQKIW,000BN)
alifornia Health&Safety Code,Sections 25505,75533 and 25534.1 1." •I rta'(� I�J
understand that lfthebulldingdom not currently have a tenant,that It bmy NEW RESIDENTIAL MECH. SQ.17.
respomiblll notitytbeomepaot of the requirements which moat be and
P,
rte emu of.Certificate Ocevpanry. city at cuperoq(t
mer or set ori loge Datej,�}] .l.Z^p-•A
- TOTAL: ISSUED BY:
OFFICE COPY