20893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE.BALL POINT PEN ONLY
Building Proed Identification - PERMIT NO.
Bulldin Addma:
20893 '
(�
weer. me: one:
aCITY OF CUPERTINO�BUILDING DIVISION �/
Centnctor'. . Lm.NO: APPLICATION 1 PERMIT D
-pt a � BMDINGELECTRICALPLUMBINGMECHAMCAL CATEGORYCONTROL NG
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Alt ��11 Lk.No: n
�q✓1 7 '7 e BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafn7Othat lim licensed!3.fhunder B.d provisions Chat Coco..d APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
Incense Is ection force of Dlvfect. (theBudnessand ProteeslonsCode,and �`
license Is in(u0 force and dreg. PANELS
License Cls® tk.N �� T
Date /o—/1 Contactor UP TO 200 AMM
2014000AMP5
ARCHITCLARATION
I understand my plans ehaR be be used used ss public records. OVER 1000 AMPS \ SQ.Ff.FLOOR AREA 5/SQ.Fi.
1e�LL U Licensed ProfessionalSIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION
{i+ SPECIAL CIRCUIT/M15C
i-, [hereby affirm thatlam exempt from Contractor's License law for the
69 following reason.ISedlon 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INSW.
110 county which requima permltto construct,alter,Improve,derrolbh,orrepair
anystmc mprkrtoiftimame,alsorequr theappUmnitorsuchpe tto POWER DEVICES
4 file a signed statement that he is licensed pursuant to the provisions of the
Oµ{{--.� Contractors License Law(Chapter 9(commending with Section 7000)of DiviV—V-
X07 sion3ofthe Businewand Prof.ss .Code)orthatheberempttherefromand SWIMMINGLELECfItIC - VALUATION
a.•33 the balls for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS H Ff
E
rmi
ppH..tfor.pet.bie,utheapplk tt..dvllp..Itydnat..than
five hundred
owner of the pr). NEW REST) AL EL STORIES TYPE CONSTRUCTION
000 Z< ❑I,as owner l the property,or ho employees with wages r their wk
comp c.7044,will Bothework mdthcetmdurebnet Wended License Law O ale(Sec. pply Business and f property
Code:The Contractors Uceme law
$$ docs not apply torn owner otproughhis wnempoy mprwvided thon,at
and OCC.GROUP RES.UNITS
EEE
who does
mentswork Mmse intended or
MsowneIf,hoee,p however,
building
or
Improvement arenotintended earofod plefior sale.If, owns-pthebu---or TOTAV.
improvement bsold within one yearolcompldbn,the owner-builderwiR have
1f�, 'den of proving that he did net build or improve for purpose ofsale.7. QTY, PL BING PERMIT FEE [NEED ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed
contractors to romtrud the pmject(Sec.7014,Business and Professbv Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EMbuild.or Improves thereon, and who contnda for - -
such Eke"with a FEE SUMMARY
15acoals)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B&P C for this reason
OUTRI DE RES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION
�t d
that I have a certltkat of consent to eel(-Ire,or FIXTURES PER TRAP SCHOOL TAX Y N
I here affirm nsu •
RECEIPT If
moo,lab
rt,Lsb CJ of arkera'Comperoatlon lnuunnce ora certi(kd copythereaf(Sec. GAS F.A.SYSTEM-1 INC4 OUTLETS FARRIER Y N
RECEIPT N
Polity N GAS EA.SYSTEM-OVER 4 TEA)
Co ray BUILDING DIVISION FEES
rCerified copy Is hereby furnished. GREASE/MDUSIRL WASTE INTERCEPTOR PLANCH CK FEE
[3CertRied mpy Is filed with the city inspection division. o� C/Q
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID o 14! 10 a 'a
COMPENSATION INSURANCE sEwER-sANITARY-STORM EA.2wFT. 'Date - Recei tic
(This uctlon need cad be ENSATI lithe permit btwone hundred dollars
(SI(10)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cerily that In the pedomunceof thework forwhlch this permit is blued,
I shall not employ any person In any counter so as to become subject to the WATER SYSTEM/TREATING
Worken'Compensstionlawsof Califomt.Date PAID -
O Z Appllant - NEW RESIDENTIAL FUME. SQFT. Date Recei til
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become sub)ect to the Worker!Compensation provisions of the Labor TOTAL:
N Code,you muatforthwith comply wlthauch provisions or this permits hall be I N
LU y deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE C7D
G FEE
t1 ]Hereby efBrmthat there b a mwtrodlon lending agency for the perform ELECTRIC FEE
3 Z ance of the workforwhlch this permit b issued(Sm.3097,Civ.C.) TOTAL:
U O Lender's Name PLUMBING FEE "
IL H LemicecAddress OTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcedifythatlhavereadthbapp0ationand statethattheatevelnformation
CL
incorrect.7 agree to comply with all city and county andlnanms and nate laws PERMIT MUANCE FEES PAID:
>- relating tobulldlngmmbuction,and herebyauthorlae representatives of this
Z: city mender upon the above�mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei isle
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,Judgments,exatand expenses which may inanyw y cave AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
against said Cttyence oft egra ntin (this permit.
`]./. PT„a, AIRFiANDLINC UIJCT(OVER 10,000CFM) CONSTRUCTION TAX
' �—fi CONSTRUCTION TAX PAID:
Signature o(AppiHAZA onOUS Date EXHAUST HOOD(W/DUC17
HAZARDOUS MATERIALS DISCLOSURE
Will the appnedby th inure Cupertino
gompanteloremhandle 9.IZ a rdoua HEATING UMT(T0100,1100 BTU) Date Recei IM
HeAhmaterial as defined by the Cupertino Municipal Code,Chapter 9,12,and the
H71Yo.5a(ety Code Section 25537Wt HEATING UMT(OVER IW,OW BTU) TOTAL: t5
Ycs �1+�—,1 Na
WRltheapplimnt orfuture building occupant use equipment ordevims VENTILATION FAN(SINGLE MID) ISJC'i'x DATE
which emit hanrdom air contandnuntsas deRned by the Bay Area Air �Iyf GS
Quality Management District? BORER-COMP OHPOR 100,"BTU)
�`��]'7 Yes ❑F'�11 r
[have read the b.9.10.terials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Hcalth&Safety Code,Sections 25505,75533 and 75514. 1 k��jlli,lt
understand?hal lithe building doss nmarrently have a[enanL that ltbmy NEW RESIDENTIAL MECH. SQ.FT
responsibilityto notify the occupant of the requirements which moat be?net --
prior to Issuance of a Certificate of Oavps ney.
Owneror aulhodeed agent Date ISSUEDBY:
TOTAL:
OFFICE COPY