20549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ll.ildln,Project Identification - PERMIT NO.
guiding Address: 2
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ams: a me: AA
CITY OF CUPERTIN6BUILDING DIVISION
G � + � qffb�� APPLICATION / PERMIT L
rBUILDIIJGE].ECRtICALI'LUMBINGMECHANIGL CATOCORY CONTROL Co/bb+
AmhXM/En Lie Na
QTY .ELECTRIC PERMIT FEE BUILDING PERMIT INFO
UM lvl��H
Address PFAMITISriUANCE F-1LICENSED CONTRACTOR'S DECLARATIONLF
Thereby af(Iren th.t lam llcrosedunderprovlWons dChapter9(cmunm APPLIANCESRF_SIDEMTAL - pg DFSCRB'HO
lice.
Infull rm and
effl 3ofNe BuslrhesadPro(mdoruCode,and
Lkeue)CIM,_ me ad dfect 0%9. - PANELS
Lkcnse Ch Lb/ V
Drteof
Cdracor
2011 AMPS
ARCHITECPS DECLARATION
0Z )understand my phm aha8h usdapub8c rscvds OVER 1000 AMPS SQ.F[.FLOOR AREA 5/SQ.FL.
O� GNS EIECT&A j Llmnxd Professional
< OWNER-BUILDER DECLARATION AaALVIR=T
IhenbyaHirm jW
that l am exempt from the Contractor's License Law lose the
d ..
following reason.(Section 70315,Budnesa and Pmfesdons Code:Any city or LE
r" oarntywhl maul aperMttpmmmc,a)ter,Impmve,dem hormpalr
6 anyawcunpdmtolbtmamc aborequb theappbantfwmchpemdt to '
0 U file a dgned statement that he b Ilocnsed pursuant to the p oW bin of the
04 Contractor's license Law(Chapter 9(commenctngwithSelon70MofDvl-
O ebn 3 ofthe Bushes and Professions Code)or that he b esnmpt the=n= NG C VALUATION
' the basis for the alleged exemp[fon. Any vielatbn of Section 70315 b/any
�A appU.tf.ra prrmlt subjects the applicant toss dull penalty dna morethan �'E
�4c five hundred dollar rill). NEW REQ ELEC3R l
�n ❑I,as owner of the property,or my employees with wages a their sob '�'�' STORIES TYPE CONSTRUCTION
t cvmpceaMion,will clothe work and theatrunun b not Wended or offaed for _
5 0 sa1e(3ec.70KPrdesbro Code The Cowadora GmmeLaw
�r3$ dm not apply to an owner of property who Wide or lmprwa tMrton,and11 000GROIJT' RIS.IIM'I'S
who dosa ichns
workhbelf fir Nrough wownemplryeez,provided that meta `
Xnpmvemeds are not Intended oroffemd forsale.If,however,the WlMlog or TOTA 5s
Improvement beoM wlthlnorcyearofcncnpletbn,tMwmerWilderwl0 have .
t rdenofpmvingthathedid notbuildorimpmveforpurposeofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE- APN
U S as owner of the property,am exchuWely,contracting with licensed L'FItM1.3.LSSIIANCE
contrarTas to construct the pro)ect(Sec 700{,B.Il eea and lid®Ions Code:
The Contractors license Law does not apply to a owner of property who ALTER-DRAIN VENT-WATER(FAL
Wild, or Improve thereon,ad who comr.m for such proje, with a
cMiador(a)Bnnsed purauat to the Cmtncars Lkn.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
t_I I am exempt order Sec B t P C for this mmn
DRAINS MOOR,ROOF,AREA,GOND. SANITARY Y N
Owner - Dale RECEIFT 1
. WOAm[ANthe I have
ISATION DECLARATION FDCrURFS PER TRAP SCI3pLg,TAX Y N
❑L hereby a(Mn the I have a mtl0cate of consent to selGwun,ora RICEPI' .
3800,Lab CJ ateo(WorYen'Cwnpersatlanlmunnco ora artifled Dopy thereof f$ec. GAS EA.SYSTEM-11NG41 OUTLTIS PARK FTE Y N
3800,
Porky/ RECF #
GAS EA.S1'SIII.1-0VER 4(FA) F
Calm gray - BUILDING DIVISION FT."
I 1CeKilled copy It herebyfurnished.thecid. CREASE/INDISMI,WASTE INTERC=R PLANCHECK FEE
Killed ropy b filed with the coy InspMbn dfvWOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID {
COMPENSATION INSURANCE SEWER EA 33�T. Date R i ted �J
(I'Heneclbn need not be completed Rthe permit is for one hundred doll
(SI 00)aWATER DATER w/VENT/ELECTR ENERGY FEE' Y
I unifyfy than in din
the performance wk ler which this pemnitbm
led, -
I sibs not employ any person In any manner ro as to become wrbject to the WATER SYSTEM/TREATING
worhere Compensation laws of Caluamla.Data ' PAID
0 Z Applicant NEW R®DFMLAI.I'11.1B. �}T., to Recei NI
Z O NOTICE TO APPLICANT:If,after mnMng ton Certificate of ExemptbR you
ehald become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Cade,yeurruufmthwithmmplywlthm&provbbroorthbpemJtdeil
W '! 'deemed rnvoked.
(L O CONSTRUCTION LENDING AGENCY M O
I hemby&III hatthenb.comtructimlendingagencyforthepedornF E ICFEE
Z arm ofthe work/can whkhthio permk b lined(Sec.30 Y/,Civ.C) TOTAL
V O I<Mer'e Name PLUMBING FEE
LL F Leodcr'a Addns - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 111
Ic,dify thadl have mad twappllottanand state that the above Information
IL bconect.IagreetocmnplywlthaRetyandowntyor iWnccsand4atelaws PERMIT CEUANCE f � D
_ FEES PAI
>. Mating to building iomtactlm,ami hembyauthorbe mpreaentathes oftw
N
U) city to enterupon the abmne_nvntbmd property for Wpectlon purposes ALTERORADDTOMECH. &7l) DatC eeel HI
(We)agree to save,Wemnify an d keep harmlem the City d Cypertlro
agaWt WbWtlm,�udgmew,mstsand expemnwhkh may d anywayamue AIR HANDLING UNIT(170 10,(100CFM) SUB OTAL:
against said City In�h+�werme of the ntingdtwprotu
C_ _._ t- Z/ AIR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCCIONTX
Sigrutum of Appbant/Cant to IXHAIR7 HOOD(W/DLJ–D CONSTRUCHO�TAPAia
HAZARDOUSMATERIALSDISCLOSURWBltheapp0ontorfuture building occupant Mom of handle hazardous HIATINGUMT=IW,(WBTU) Date
material as defired by the Cupertino Municipal Code,Chapter 933 and the -
IIr.lth a Safdy Code S ition 25531(a)7 HEATING UNIT(OVER 1W ODD BTU) TOTAL:
❑ Yes ,t+�-,1 No
WOltheappO mM futon Wildingoaupmtuseequlpmeruordevkos VENTILATION FAN(SINGLE I=) ISSUKWP[ ,TE
hkh emit hazardous air rontamlnsnts a deBred by the Bay Arta Alr:
• sIity Marugement D(strlct7 gOm i;p-NMP PFB'OR 100,000 B7V)
YyeaF� JUV
have read the hazar7ous materials requlremenb under Chnpler G95 of BOILLR-000MP L00,0008T1J7
the Califcrnb Health k Safety Code,Sections 25505,25533 and 15531.1
uMaratand that lithe Wildln ceiwtamertUyhaveatenant.that it is my N'EWRESIDEMULMECH. SQ.FT C/;;4,,1f PM,e.{;no
pns oly to notify tM1c rat dthe mentawhkh oust be met
rn
prlort erre a to of Oma
ner w author)�agen Uate
TOTAL:
OFFICE COPY