20537 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY.
Building Project Identification - PERMIT NO.
Building Address::, 20537
wee
one: q t•rn �.-� CITYOF CUPERTINO-BUILDING DIVISION
ContpWia jJacon: le.N 'APPLICATION / PERMIT -
H� BUILDING-ELECTRICAL-PLUMBING MECIUMCAL CATEGORY CONTROL p
�. Amhlt /Engineer. 'LIc.Nd.
cjA l2 CAAiN •.EGECTRI�.PE�i?MTT t'y'.,:.FEE, ' `'BUILDINGPERMITINFO', -_ ..
El 0
Address: I � /' ' 10 jn(J ,G� yr�¢ J � PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION �.
I hereby affrothat l am licensed under provisions of Chapter 9( nom
APPLIANCESRF.SIDENTIAL JOB DFSCRE'TION
Ingwlth5 dion7000)of Dlvlslon3ofthe Buslnessand�'rPfesurnsMan
I le In full(o�9�ad dfect � Y^_ � I `1 - PANES ' (���< ` , `fes ,
I CI _1 L� LieN C�l 1` VJ6`T��
Date- Contractor N +
ARCHITECT'S DECLARATION 201-IODOAMPS ,
W% I understand my plans shall be used as public records - OVER100DAMPS - SQ.FT.FLOOR AREA $/SQ.Fr.
NO Licensed Professional SIGNSELECTRICAL'•
OWNFR-BUILDER DECLARATION BPFALILCIRCUR/MISC
7 3 I hereby affirenthxt I am exemptfromthe Contractor's License law for the
oo following reason.(Section 7031.5,Business and Professl...Cade:Any ctty or
O Z F. TEMP.METER OR POLE INST.
�,E county which requires permit to construct,alter,improve,demolish,oreepair
g anystrud mpr rwitsl mancqalsorequirestheappliontforsuchpermitto -
PJ O � file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
GBl Contractor's License Law(Chapter 9(mmmencing with Section 700))of Dist. SWIMMING POOL ELECTRIC� VALUATION 0 aion3 oftheBusinessand Professions Code)orthat he is exsmptthercfromand
yyy the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES �O/-n �`
applicant fora permit subjecm the applicant to a civil Penalty of oot more than UJJ
five hundred dollars($500, NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their sole SQ'FT' STORIES TYPECONSTRUCTION
comNssatlon,will dothe work,andthe structure is not Intended or offered for
sale(Sec.701y Business and Professions Code:The Contractor a License law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who does suchwork himself orthrough his own employees,provided that such
improvements are not Intended oroffered forsale.If,howeveq thebullding or TOTAL:
Improvement esoldwilhin oneyearofcompleiogtheowner-buBderwill have
th,�e +rdenofLovingthathedidnotbuildorImproveforpurposeotsale) QTY. ``, ",p4[jMgING'.PERINIT 'rFHE'!` FL000wNE ArN
LJ L as owner of the property,am exclusively contracting with]Icenxd PERMIT ISSUANCE
contractors to corestruct the project(Sec.7044,Business and Professions Code: -
T'hs Contractor.License Law does net apply to an owner of property who
contracts k VENTWATER(EA)
builds or Improves thereon,and who contrafor such pS -
ojects with a - 't�`. FEE'SUMMARX
[,Il!j.[actor(s)Ilcensed pursuant to the Contractors Licenm Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B 4 P C for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner • Date RECEIPT#
40 WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to selMnsureora pL%{QggS PER TRAP SCI{LDL TA% Y_ N_RFCEB'C#
certifimteo(Workem'Compemationly mnmaramrtifiedcopythereof(Sec. GAS EA. INC.40UTLEl5
3800:Lab CJ PARK FEE Y_ N_
Policy#
Com ny GAS GST
.SYCM-OVER41 MA) BUILDING IVISION FEES
C
an GAS
cocopypy U filed V hereby witumiththe ehcityed.impaction d ivbion. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑ . . .
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE �
'(This section need not W complMed[(the pemN[Is!Drone hundred dollars SEWER-SAMTARY-STORM EA.200rrr Date Recel t#
($100orless.) - " WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
[certify Nat tribe performance o(the work for Nch Nle permit is Issued, —
'IshallnotemployanypereonIn manner t beans�In tothe WATER SYSTEM/TRFATING
Workera'Compart1ertmr(N woof Ito Yl V PAID
0 Z Applieant ^
NEW RESIDENITAL PLMB. SQ.Ff. Date �Recei t#
Z O NOTICE TSI ANT:ILaftermakingthis Certifioteof Exemption,you +
Hshould become subject to the Workers'Compensation provisions;of the Labor - TOTAL: l
c N Code,you must forthwith comply with such provisions orthis permit shall be BUILDINGFEE
deemed revoked.
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a onetruction lending agency for the perform - TOTAL: ELECTRIC FEE
Z ante of work for which this permit E Issued(Sec.30W,Civ.C.) '
u 1<nders Nacre PLUMBING FEE
LL 1= Lendara Addreae Qac:'{:;�"MECHANICALthERMIT -' `='"r FEE',` MECHANICAL FEE
O W 1certifythatl have read thlsappliratiunand statethattheabove(nlormatlon
S iscorred-I agreeto comply with allctlyand countyordinancesand statelaws PERMIT ISSUANCE FEES PAID:
} N.. relating to Wilding com uction,and hereby authorize representatives of this -
,� Z city to enter upon the aWve-mentioned property for inspection purposes. ALTERORADDTOMECH.. Date Reeel t#
V _ (We)agree save,Ind 1 an ep harmless the City of Cupertino p
'against liabll @me a which may In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) _ SUBTOTAL:
agalwtsai i ro sect - 'an �t3hle pe it
g0 LIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
a �-9
Signatu o Applicant/Contractor - Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
` HAZARDOUS LS DISCLOSURE
Wi the app. Witting occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
mate lasdefined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reeei t#
Tic filth and Safety coda Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL•
❑Yes No
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ,x f, DATE
which emit ha,cardous air contaminants as defined by the Bay Area Air �Urt! V s'7 - .
Qu ality Management District] EOILER-COMP QHP OR 100,0()BTU)
i Yes n No
4haereadthehazarR.,ortaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) /� .�y�a�aaaa
theCaliforniaHealthkSafetyCode,Sections25505;25533and25534. I 'nl�l O,cups LL4IY
understand that it the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility,to nosily the occupant of the requirements which must be met
prior to issuance ofs Certificate of0ccupancy.
Owuer or authorized agent Date - ISSUED BY:
' TOTAL:
OFFICE COPY