20488 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address;
20488
g 6
wnere ante: p one:
/5/Qp(AJ� CITY OF CUPERTINO-BUILDING DIVISION
c attm: me: Lk.No: ! APPLICATION /PERMIT
BMDINGELECnUCAI PLUMBINC-MECHANICAL CATEGORY CONTROL M
Architect/Fnglneer. Lk.No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE �B O El l y� D D
LICENSED CONTRACTOR'S DECLARATION JOB
IhthSy tlrmthat)of Di Bcensed 3oftheunder sinemadProfehapter9(e,and APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
Incense I I.fon to.and effean3o(the BuslnemandProlessionsCade,and my
license b in full force end effect. PANELS
License Clam Lk.N pv4 w -e
Date GHITIE Or 201IMAMPS UP TO 2DQAMP-qr �/L� ►•I/
ARCNall be used
DECLARATION
p�p�uu re0 2 I understand my plana shall 6e used m public records. OVER 1000 AMPS SQ.FT.FLOOR 5/SQ.FL.
k ou Licensed Pro(emlonal - SIGNSELECTRICAL
<<
OWNER-BUILDER DECLARATION
I�n SPECIAL CIRCUIT/M19C
Z L.,GI I herebyafRrmihat I am exempt/nom the Contrattor'e Licenm Iww for the ��p
Pg�O a following reason.(Section 70315,Budoe a and Pmf edlons Code:Any city or (Q_W
countywhlchmqulresapert ttommtmct,dteglmpmve,demolbh,ormpair TEMP.MCCIXOR EINSL \\
any structure prior to its issuance,also requires the applicant for such pemdt to
POWER DEVICES
Ne a signed statement That he is r 9(cced pursuant it the provisions of the
3w� Mon 3 ofthe Licensusire Law(Chapterwith xection mpttherefof Divi- SWIMMING POOL ELE C
don3ofthe Buslneasand ProfemlamCode)orthat heisexemptthere(rom+cad VALUATION
O the hada for the alleged exemption. Any violation of Section 7(015 by any OUTLETSSWITC - H
applicant for a permit subjects the applicant to a civil perm lty of not more than
0ue F11,a sr owner dollars hepr. SQ STORIES TYPE CONSTRUCTION
NEW RFSIDFNR3A L Ff.
7< compensation❑I,sa owner of the property,d my em tune in with wages as their tub .
kc. 1will do Business worksessthe sbuatureh not Intended oroffered for
❑
Is(kc.
apply
Business owner
mif property Code:TM Contractors License,Law
$ don omsucyroan owner of throng hiswho Wild.
emplrlmpmovidedreoRand OCC.GROUP RES.UNITS
who domauchwork hlmmBarthrough Msown employen,provided that such
Improvements are not Intended proffered formic.If,however,thebulldingor Vouk0
Improvement bmidwlthlnomyearofcompletlokthe owner-bu0derwillhave
the burden of proving that he did nmbulld orlmprove for purposso(sale.). QTY. PL G ERMIT FEE
F-1 I,as owner of the property,am exclusively mntracting with licensed FLOOD 7ANE� MIN
The Contractor's
e. IM(Sec.764y Buslnem and Profession.Code: PERMITMU E .1
The ContractoYs License Lew don not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such ptieods with a ALTER-DRAT VENT W
cgR((+cmr(a)licensed Pursuant to the C.M.d./a License Law. FEE SUMMARY
off1=1 am exempt under Sea B k P C for this remon BACK FLOW PROTFLT. E 11 OUTSIDrfErS
DRAINS FLOOR ROOF, SANITARY Y- N
Owner Date— RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAK Y N
❑I hereby orke that I have• lmumne of consent to pytheure,ora RECErr M
certifkal,C.) rkas Compematlon lr.unnceora cenifkd mpythertaf(Sec. GAS EA.SYSTEM-1 Of PARK FEE Y N
350Q lab C.)
Policy tl RECEPr NGAS FA.SYSTEM-OVER 4(EA)
Com any � BUILDING DIVISION FEES
Certified copy la hereby te ty
-eructed copy b(Teed withh the city inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CRE'ASETRAP PAID
COMPENSATION INSURANCESEWQLSANfTARY-STDRM EA ZOOFT' Date Remi t#
(This section need not be completed If the permit Is forone hundred dollars
loss)
(51(D)orem) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify at N m
the performance of the work for which this permit b issued, -
I shall not employ any person In any manner so as to become subject to the WATER SYS.IFM/TRFATING
Workers'CmrFxmsallon Taws of CaRfomia.Dale PAID
O Z Applicant NEWRESIDEN'DALPLMB. SQ.FT. Date Recei t#
Z NOTICE TO APPLICANT:If,after maydng this Certificate of Exemption,you
should become subject to the Workers'Compensation prokion.of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall he BUILDING
FEE
LU j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebya((Irm that there ise construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z anceo(theworkfor.whkhthb permitisiswed(Sec.3097,C1v.C.)
() O Lender's Name PLUMBING FEE
IL — Lenders Aaarem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW bmIcert lfy that I have ad this application and state that the above information
1 rrect.l dgme to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building coratmoteon,and hereby authorLm repreeentatNn of this
N _ city to cote upon the above m41 �.Pj
pe for Inspection purposes. ALTER OR ADDTO MECH.
2 (We)a ee to cove,indemem the City of Cupertino DateReceipt#
go1 Iltiea,judgment, which nay In anywayaccrus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
gd dClty In tuna raof thea permit. _ AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Slgnatu mAptt/Contractor Date/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MA ERIALS DISCLOSURE
Wilt the app[ ntorfuture building occupant store or handle haeandom HEATING UNIT(TO IDO,ODO SM Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.1Z and the
He❑a1t.ml Safety Cod1 cf.n2S532(a)? HEATING UNIT(OVER l00,OW BM TOTAL:
Yes In No
Will the applicant or fu future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSU ATE
which emit hazardous air contaminants as defined by the Bay Area At, ny
Quality Management District? BOILER-COMP ptm OR 100,DW BM 1'�/lV 311990
T I 7QQn
Yes n No li 1 J 'siseae
have read the hazy pus materials requlrefrent under Chapter 6.95 of BOILER-COMP(OVER 100,000 RIM
the California Health k Safety Code,Sections 25505,25533 and 75534.I a{ i.
understand that lithe building dm not corrently have a tenant.that It is my NEW RESIDENTIAL MECH. SQFF. City yT Capedmo
rnporeslbility to notify the occupant of the requiremontewhich moat be met
prior issuance ofa Certificate of ancy.
or, I/? ,/ L- . ,e)E�Q.P, 5=3/-
Ownerorautho agent Date
� TOTAL: lSSUEDB '
OFFICE COPY