20751 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�� Handing Project Identification - PERMIT NO,
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'Building Add
20751
G.- aU CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: LIc,No: APPLICATION it PERMIT 3
BUILDING-E.FCTRICAI PLUMBING-MECHAMCAL CATEGORY CONTROL 0
Architect/Englocem .Net
F 'Q'IYr ELECTRIC PERMIT FEE , BUILDING PERMIT INFO
Address ry �YS 1X & ` A) ^ Je I PERMITISSUANCE 12.Cy' (�
`LICENSED CONTRACTOR'S DEC RATION
I hereby affirm that l am licensed under provisions of Chapter (courramere APPLIANCES RESIDENTIAL `� JOB DESCRIPTION
Ingwith Srdion7000)of DWielon 3ofthe Busincusand ProfeulonsCods,and my
Ilcense is In fun force and effect. PANELS
Li CLiss Lk.N I I^'t C� (y,d �-
Data �DJQ/
Date Contactor lUP TO 2DO AMPS
ARCHITECPS DECLARATION 201-1000AMPS
OZ Iu rstyn�fnyrylaru be used upublcrcmNw OVER 1000 AMi'S SQ.FT.FLOOR EA � $/ Ff.
{Qw CG m I � 7
EU Llr�i�dC�, 1 r' li/ J SIGNSELEGTRICAL -ED1
<�6� OWNSR-BUILD ER DECLARATION SI'ECIALCIRCMT/MISC
a., Ihereby affirm that l am exempt fromthe Contractor's License Law for the
Z 0...p fonowing reason.(Section 70315,Business and Professions Code:Any city or T ■�ssf•
O ZI- TEMP.METERORPOLEIN
P county which requires a permittomutruct,alter,improve,dernalish,orrepalr
QEg anystmcture p0orto lh lswance,aborcqulrestheappBantfor such permit to POWERDEVICES '
Me a signed statement that he ii licensed pursuant to the provisions of the
X3µ+ Contractors License law(Chapter 9(commencing with Section 7000)of Divi. SWIMMINGPOOLELECTRIC
I-,E00 elon3ofthe Buslnesand Pro!esslonsCde)orthat Fele exemptthercfromand ALUATION
o the basis for the alleged exemption. Any violation of Section 7Q11.5 by any OUTLEISSWITCHES FIXTURES �� D
applicant fora permit sub)ectsthe applicant to a civil Penalty of nut mnrctlun Int
6
five hundred asrowerrofthe pro NEW RESIDENTIAL ELECTR SQ}7. STORIES TYPE CONSTRUCTION
0.. ❑I,as owner mf the property,or my employee with wage as their sole
compcuatlon,B.I Bothe work and thestucture V not Ntendd or offend for
sale(Bee 7614,Bualneas and Professions Cdr:The Contractors License Law
d.sot apply to an owner of property who Wilde or improves thereon,and
r-s^ whodoeaeuch work himself or through his own employee,provided that such OCC.GROUP RES.UNITS
improvements are not Intended oroffered forsale.If,hmvever,thebullding or TOTAL: 1
improvement V sold withinoneyeamfcamplmiom theowner-buOderwill have
t e L as Iden of proving that he did not Wild or Improve for purpose ofsale.), QTY, . PLUMING PERMIT FEE FLOOD ZONE APN
owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE I
contractors to construct the project(Sec.70K Business and Profd2x Messlou Ce: <
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improve ry jecta thereoand who contracts for such,ptowith a
cWLtlactor(e)Iimnnrd pursuant to the Contractor.License Law. FEE SUMMARY
1�I am exempt under Sec B k P C for thio reason BACKFLOW PROT[CT.DEVICE
OUFM 5F Ft I-K
Owner Date
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
RECEI7 Y
WORKMAN COMPENSATION DECLARATION Lt FDCIURE.S PER TRAP /ny SCFIOOL TAX Y N
❑1 hereby affirm that I have o certificate of consent d spythsure,ora R V x� RECEPT p
3901,LateofWorkers ComperuaHonlnsuanceoracertlfief mpythemo((Sec. GAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y N
Polis lab CJ
CffC ' GAS EA.SYSTEM-OVER RECEIPTp
Com any BUILDING DIVISION FEES
❑PCertlfied ropy is hereby tthe cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑CeOifid copy is flied withh the city Wpmlon division. 1 V
CERTIFIG OF EXEMSATIO I FROM WORKER,'
GREASC TRAP PAID 1�•
COMPENSATIONINSURANCfi SEWER.SANOARY-STORM EA p6F1. Date . Recei t#
Rhlssectimn need not W completed If the permit iafor one hundred dollars
(810)()orlen.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
I ll not that o anyhe person in an lmannerhework so as to b comehis er subjeit isct
tofirstheod, t�'r1
I shall not employ any person In any manner m u to become mrb�rct to the a
Workers'CompenuHon Gwa a(CaII(omWATER SYSTPM/TRLAT7 NG
la.Date PAID frtl
W -
0 Z Applicant NERESIDENTIALPLMIL SQFf. Date Recei t#
Z 0 NOTICE TO APPLICANT:11,after nuking this CeOBlate ofExemption,you
should become him the Workers'Compemat Ion provhlmu of the Labor TOTAL:
W Code,you=at fan hwith comply with such provisions or this permit shall be BU IN
W G deemed revoked. '
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency forthe perform ELECTRIC FEE
D Z ance TOTAL:of the work which this permit la Issued(Sec.3097,Civ.C.) ZQm t.
U 0 Renders Name PLUMBING FEE Q�
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
oU I cekifythatl havereadthlsappliatlonand statethattheabovelnformallon 1 - .{.�
W is correct.R agree to comply with all city and muntyordlnancu and mate laws ` PERMIT ISSUANCE a ESO FEES PAID:
} IL relating to building construction,and hereby suthoHze representatives ofthis
U) city to enter upon the above,mentlonetproperty for Inspection Purposes. 1 ALTERORADDTOMECH. Z,xCX)
(We)agree to rave,Indemnify an d keep harmless the City of Cupertino Dale Receipt#
V
against liabilities,Ndgmenus,costsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Sigrature of Applicant/Contractor Date D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or ha odic hazardous HEATING UNIT ITO 100,000 BM Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hes lth and Safety Cod r;Sgdion 255320)7 HEATING UNIT(OVER 100,000 BTM TOTAL: 3i4011Lt1__'
El Yea t.{_71 No
Will the applian rfoture building occupant use equipment or devices VENTILATION PAN(SINGLE RIiSID) ISSUANCE DATE
which emit hazardous air coma mina eta as defied by the Bay Area Air
Quality Marugerrem Dist2 IIOILER-COMPOFI'OR100,0WBTM OOO
(❑''j Ye No ` p
I have read theft at ous materials regWrcmentaunder Chapter6.95of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Cde,Sections 25505,25533 and 2:530. I rt V yam✓"
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT t,W
rc�pcuibility to notify the panloftherequlrementawhichmu beret `W la'�6S41C.kra/•T'/%
Prior tom e of IR u panty.
/3 d
error. da" pat I ISSUED BY:
C4o&) rIZ-3- l O OFFICE COPY