20214APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT, PEN ONLY
Bulldin Pro'eT ldentlfkaHon ,,
Building Address: v o v Y f��
PERMIT NO.
_ 20214
nere eros: one: -
p
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT
Contract'Name: Uc.Na
2224 •
BUILDING-ELECnUCAI PLUMBINGMECHAMCAL
CATEGORY
CONTROL X
Arch to neer. tea, .�X� - ` Lk, Nro;
1 C C_ ` l W
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
_S�
Address: _
PFRMITISSUANCEE:1
ElLICENSED
CONTRACTOR'S DECLARATION
]hereby affirm that l am licensed under provisions of Chapter 9(commenc-
7000)ofddieon3ofthe BuslnessantlPro(essloneCode,and my
licame1 in
license ie In full( end sf.* /^/�
License lase LIc.X�/
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
Date Contra orUP
TO 2DO AMPSv
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
'
OVERI"AMPS
SQ. Fr, FLOOR AREA
$/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyafflrmthat I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
c htywhichrequlresapermittoconstrua,alter,4 pmve,de=o h,orrepalr
anystrumm pdortoits issuance, also requlrestheapplicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provbiaru of Me
ston3 of the Business and ProfessionsCods) orthat hell exempttherefromandVALUATION
the basis for the alleged exemption. Any violation of Section 70313 by any
Contractor's Liceme Law (Chapter 9(commencing with Sectlon 7000)of Dlvl-WLEL.
appBrant fora permit subjects the applicant to a civil penalty of nae mare than
dollar
live 1, as nrof thepr.
I, asowner of the property, or my employees with wages
their dolecompensation,
SPECL1LCBtCU1T/M
TEMP.MECFRO LE
ppWgg DEVICES
'
TS -SWI
STORIES
TYPE CONSTRUCTION
work and r
not Intended cur offered forsale
(Sec B.,des,aothe
Business and Professions Code: The
ionthes Code: Th m
Uceree Lawwhodoes
pply or i roves
ti t apply roan owner ofpenughroperty iso nemWildorimproovided thatsuch andOCC.GROUP
whoovementse g,ch are workhimself edoroughed owns. If, ho a er,the buildingor
Improvement issold intend-dyr.lfcomprsale.iheo evegtheerwflI have
Improvement wlthlnoneyearo(complctioMtheowner-bu0derwBlhave
t1A.kuIdea of proving that he did not build or improve for purpose of ukJ.
u L as owner of the pmperty, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contmdors License law does not apply to an owner of property who
builds or Improves thereon, and who contracts-
for such PWjects with a
co[�0TTactcr(s) Bcensed pursuant to the Contractor's License Law.
LJ I am exempt under Sea B & P C for this reason
TO AL:
QTY, PLUMBING PERM] FEE
PERMIT ISSUANCE
-
ALTER -DRAIN &VENTWATER ffA)
RES. UMTS
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIX.Il1ItFSPER ,
SANITARY Y N
RECEIPT X
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby af(lmn that I have a certificate of consent to sgFirsam, ora
rtificateofWorkere Compemationlmumnce ora certified copy thereof (Sec.
3800, lash CJ
SCI{1pLTAX Y N
N«
RECEB
CAS EA. SYSTEM -1 WC.40ITILEfS
PARK FEE Y N
Policy a
RECENT p
Com an Y
GAS EA.SYSIFMOVERd(EA)
BUILDING DIVISION FEES
ertiBed ropylshereby (umlahed.
CertNed copy is filed :,x th the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
GREASETRAP
" CERTIFICATE OF EXEMPTION FROM WORK ERS"
COMPENSATION INSURANCE
Cot W completed
(Thlscectlonneed notbecompletedNI permit Is foram hundred dollen
($lMorleas')
I certify that N the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner so as to become subject to the
Workeri Compensation Uwa of California, Date
Applicant
NOTICE ca APPLICANT: a ager making thiosationk ro of Exemption, you
should hem us subjectforthwith
the Workers'Compensation n pmvbim permit s Labbe
Cedgyou must forthwith comply with each proWbv or this permit shall be
deemed revoked.
PAID
Date RIXXI t#
SEWER -SANITARY -STORM EA 200FT aa.,,�X�ss
W
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQFr.
TOTAL:
BUILDING
TOTAL: '.��1
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constmctioniending agency for the perfomry
ance of the work for which this permit is Issued (Sec. 3097, Civ, C.)
Iaaders Name
Lenders Address
I mrtifythat I have read this application and state that the above Information
ls correct.I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorlre representatives of this
city to enter upon the above-mmuloned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities,
ties,judgments, costs and expenses which may in any way accrue
against acid City in consequence of the granting of this permit.
ELECTRIC FEE
�LJC)
QTY. MECHANICAL PERMIT FES
PERMIT ISSUANCE
ALTERORADDTOMECH.
HANDLING UNIT(TO 10 ,000 CFM)
PLUMBING FEE
„m
MECHANICAL FEE
FEES PAID:
Date Recei f#
P
SUBTOTAL:
AIR 7{ANDENG UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 1(0,10 BTU)
Will the apperant or future building occupant store or handle hazardoua
material as defined by the Cupertino Municipal Cade, Chapter 9.12, and the
Date Recei t#
HEATING UNIT (OVER 10,000 BTU)
TOTAL:
cW
Health and Safety Code Section 255324)7
❑ Yes fi� No
VENTILATION FAN (SINGLE REND)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit haaardous air contaminants as defined by the Bay Area Air
BOILER -COMP OHPOR 100,000 BID)
Quality Management District?
❑ Yes ❑ No
BOILER -COMP (OVER 100,D00 BTU)
Ibave read the hazardous materials requirements under Chapter 6.95 of
the Gllfcrnla Health & Safety Code, Sections 75505, 25533 and 25534. I
,
NEW RESIDENTIAL MECH. SQFI.
understand that if build Ing does not currently have a tenant, that it is my
rmponsibll' a notify the occupant of the requirements which must be met
priorto a ceola CertificateofOttupancy.
ISSUED BY:
Ow or au ge t, Data
TOTAL:
OFFICE COPY