20925 (2) APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project Identification PERMITNO.
BWldingAddress: 20925
x _ 5 S+e(I� 4 -099
Phone: CITY OF CUPS NO-BUILDING DIVISION 6_-i p_a O -
G.^tractoer N l•{I ' LI=:No: APPLI TION I PERMIT 6_-j.&
L
BUILDI AILPLUMBING.MECHAMCAL CATEGORY CONTROL p
Architect/Engineer. Llc.No:
'QTY P FEE BUILDING'PERMIT INFO
Address: P AN ��Qd ❑ 1� ❑ El
CONTRACTOR'S DECLARATION �J
Ihereby ior,70that l iv liceMonsed 3aitheerpramand mfe"on,ofChapter9de,and c N JOB DESCRIPTION
Incense I.I.Eau force and
died. ltheBusinssandproleeloneCode,and my
license tela(uB tor__. Lif(ect.
License Gross Llc.p
Dale Contractor TO 200 AY 11�
ARCHITECT'S DECLARATION I-1000AMPS
qM2 I understand my pmnshallbe used as public records. OVER 1000 AMPS SQ.Fr.FLOORAREA $/SQ.FT.a O
k� Llcenred Professional SIGNS ELECTRICAL
<QQQ Q OWNER-BUILDER DECLARATION
I'n SPECIAL CIRCUIT/MLSC
Z f. I herebyaffim that I am exempt from the Contractors License Law forthe
p Q following reamn.(Section 70315,Business and Professions Code:Any city or
county which requia permit to construct,alter,Improve,demoltsh,or repair 7EMP•MEf1R OR POLE INST.
m
q'1�1 anystrucom prierto its bsuance,amo requirestheapplicant torsuch permitto pOWEg DEVICES
6 a file a signed statement that he b licensed pursuant to the provisions of the
Ow Contractor's License 3 O�sn Law(Chapter9(commenchingwlthSect1on7000)ofDlvl-
SWIMMING IVOL ELECTRIC
sion3otthe Businesand Pm(emloruCodeo [ at hats exempttherc(rmand �S VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any LE OUTLETS-SWITCHESi,AE
O applicant Earn permibubject@ the applicant to a civil penalty of not more than
$ Iva ndred delta.($500). NEW RESIDENTIAL ELECTR SQ.Fr, STORIP5 TYPE CONSfRUCTim
�. I,as owner of the property,or my employees with wages as their sole
nation,will do the work and the structure is out Intended or offered for
p le6m.70K Businessrad Profexloru Code:The Conlmanes License Law
�$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROIII' RES.UNITS
who doessuch work himself or through Msown employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL: (L.t,,(Z
improvementbeoldwithinoneyearofcompleiogtheowner-W Rderwill have
t),L]Iurden ofproving that he did act Wild orlmprove for purposeotsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
u I,as owner of the property,am exclusively roll tlRB with Ilrensed PERMIT ISSUANCE
contractors to construct the pmjed(Sec.7654,Business and profession Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such pLojecN -
with a - - FEE SUMMARY
151
clueW licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
am exempt under Sec. - B&P C for that reason _
OUTS I UP FEu
DRAINS.FLOG ROOF, SANITARY Y N
. Owner Dace R AREA.GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N
QI hereby affirm that I have a certificate of consent to self-lasure,ora ftirm�.p
cenlfiate o(Worken'Compensation Insurance or a certified copy thereof(Sec.
3800,Lab C.) GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy p GAS-EA.SYSTEM-OVER d(EA) RECEIPT'X
Com any tlU1LDINC DIVISION PEES
Certified copy b hercbyth the od.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy m(fled with the city inspection divlelon. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAI' PAID - -
COMPENSATION INSURANCE SEWER- STORM-STORM EA 20017 Date Remi t#
(Thlsaectlon need ncl becompleted If the permit bfor one hundred tlollan
($1I mnffess3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
IcertRy that Nthe performance.(the work(orwNch fhb permit isbwed,
I shall not employ any person In any manner so v to become subject to the WATER SYSTEM/TREATIN'G
Workeri Compensation Lawson Califomb. Date PAID
O Z Applicant NEW RESIDENTIAL PWB. SQ.FT. Date Recei f#
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compe satlon provision of the Labor TOTAL:
N Cade,you must forthwith comply with such provisions or this permit shall be BU
LU ] decnsd revoked.
ILDING LITE
tL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyatRrmthat thereaconwctlon lending agenperform
:) Z ince of the workfor which this permit bbsued(Sec.3097,Clv.CJcyfor.) TOTAL: ELECTRIC FEE
02 Lender'.Name - PLUMBING FEE
LL H Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FBE
O,W IceditythaH have mad thbappBallonandsatethatlhcabove information
bcorext.l agreeto comply with all etyand county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
} O- misting to building construction,and hereby aunbutton representatives;ofthb
I.- Z city to enter upon the above-mentioned property for Inspection purpose. ALTERORADDTOMECH.
Date Recei f#
— (We)agree to save,indemnify an ci keep harotess the City of Cupertino
against liabilities,judgments,cosband expenses which may In anywayaccme AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL'
against said City in cons core of th it of this permit
AIR HANDLING UNrr(OVER 10,00(1 CONSTRUCTION TAX
M 0
'Ignatvrco(A plirant/Contractor Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI OSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Dale Recei 1#
material as defined by the Cu pernao Municipal Code,Chapter 9.1 Z,and the _
I leallh and SafetyCade Section 7553Z(a)7 HEATING UNIT(OVGR 1 W,000 BTU) TOTAL:
❑ Ys .
Will the applicant o,,Kmum building ompant use equipment.,devices VENTILATION PAN(SWGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP OFB'OR 100,009 BT(I
4 Yeo
haveris eeth& out materials requirements under W3aChapter6.95.E BORER-COMP(OVER 100,OOl1BN)
the erst.nmta Health&Satiny Code,Sections 25505,2W3 a t and,5535. Icrad
rmpomanlitytod that fthe fy the occupant
of to rrently equireent.tenant,that It many NEW R65IDFN77ALMECH. SQ.FT.
repnnlbiiitymn.ti(y the occupant ofthe'requircmenta which must be rant
prlortolssua sofa Certitl.S to otOmp cy. -
veer or auth agent/4_ Date x
TOTAL: ISSUED BY:
OFFICE COPY