20690APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE RAI L PnINT Ppm nmi v -
Building Project Identification -
- Bullding Address:
a�a
- - - — PERMITNO.
Ol6 uJ /� ^ O
wnere Name, one:
•.
CITY OF CUPERTINO-BUILDING DIVISION
/ PERMIT
BLJILDINGELECTRICALPLUMBINC-MECHAMCAL
A
' -
Contra " rm: Lie. N.APPLICATION
ell hJ
V
Arc lied/Engineer. Lk. Na
CATFCARY
CONTROL M
QTY ELECTRIC PERMITFEE'
BUILDING PERMIT INFO
Address: _ r
PERMITISSUANCE
-
LICENSED CONTRACTOR'S DEC
[hereby dflrtnthat lalicensed under providonso(Chapter9 (comment-
Ingwlih Section70fA)om f DiW$1=3ofthe BudnenandPrvfe-sion4Codgand my
license Is In full form and effect.
License Cissa
Date .Contractor
ARCHITECTS DECLARATION
I understand my pIs--bell be used as public records, - .
Prfemloml
DECLARATIONSPECIALC]RCUIT/MISC
I hereby affirm that lam exempt from the Contractor'. License Law for the
m...(Sedeon 7031,5, Businee-aad Professions Code: Any city or7'p�(P•ML-TLP
requires a permit tomartruat, alter, Improve, demmllah, orrepalr anyatmu mPrbrtoitsism-a.,alaorequim.theapplimntfwsuchpert ttoppWp((DEV[CESfile a signed statement that he is licensed pursuant to the provlslone of theGntrsetm'e License Law(Chapter9(commendngwithSedbn7000)o(Divl-gWEs(M(NC
Ccal0rrthat he is exempt therefromand
the basis for the dinged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty d not mo -than
five hundred dollars ($500).
❑ I, as owner of the property, or my employeea with wages as their sok
rompensatlon, will dothe work, ad the structure'. not intended or offered for
sale (Sec. 7094, Business and Prni.ioes Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon,and
who does such work himenforthrough his own employees, provided that suchOCC,GROUP
Improvement-arenotintendedorofferedfo ole. If,however,thebuildingor
improvementissold Mthln oneyearofmmplelon,theowner-bu0derwillhave
t)akurden of proving that he did not build or improire for purpose ofsxkJ,
LL�J L an owner of the property, am exclusively contracting with licensed
rontndon to comstructthe project(Sec. 7046, BusMem and Profeasloru Code:
The Contractor's License Law does not apply to an owner of property who
bu Bds or Improves thereon, and who contracts for such p4oject- with a
cgB�T�dor(-) licensed pursuant to the Contractor's License Law.
LJ I am exempt order Sec. B 6 P C for this reason
APPLIANCES -RESIDENTIAL
PANELS
JOB DESC ON
-,yt,iLQiCJ(/�J
201-1 (100 AMPS
OVER 1000 AMPS.
SQ.Licensed
SIGNS ELECTRICALOWNER41TILDER
'following
ORPOLE INST.cmuntywhich
POOL ELECTR[Gslon3oftheBuelneeeandPro(eskm
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQFI,
STORIES
TYPE CONSTRUCTION
_
RFS. UMTS
TOTAL;
QTY, PLUMBING PERMIT FEE'
PEgMI.I.ISSUANCE
ALTER -DRAIN & VENT -WATER IEA)
FLOOD yp
�N
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date -
DRAINS -FLOOR ROOF, AREA, COND.-
-
FIXTURES. PER TRAP
SANITARY Y_' N -
RECEIPT R
WORKMAN COMPENSATION DECLARATION'
'❑I hereby affirm that'I have a certIDcate of consent to self -insure, or a
rediflcate of Workers'Compemationlrmumnce or a certi(ird mpythereof (Sec.
3800,Lab C.)
Policy M
TOOLTAX Y_ N_
RECEIPT a
CAS EA. SYSTEM -1 INCAOUTLtiM
-
PARK FEE Y_ N_
RECEIPT p
It
Com any -
GAS EA, SYSTEM -OVER 4(EA)
BUILDING DIVISION
ION FEES
[�CedlEed copy is herefiled w tumbhrd.
�Cedlfird copy M filed with the city Irupedlon division.
CERTIFICATE OF E)(EMPIION FROM WORKERS'
COMPENSATION INSURANCE
need not becompleted lithe perirdt bforuns hundred dollare
(SI IIO)orlenJ
lax
I cent that employ an prexa in any manner so as tobehis permit c booed;
I shake not employ any Person in any manner so as to become subject to the
s'Compensadon Laws o(GmM
llfa. Date
Applicant
Applicant
NOTICETOAPPL9CANT:I,aRermaking this Certificate of Exemption, you
shoutdbecomesabject to the Workers' Comperudeonpervinkme.fthe Labor
Code,yrurwst(mthwlth comply with such provision or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY -
Ihercbyaffirm that them be ones on kndingagenry for the perform
saw of the work for which thin permit b bsund(Sec, 3097, Civ. CJ
Lender's Name
Lender'.Addirss
I ced lfy that have read this application and state that the above information
iscorred.I agree to compiywitb all dtyand county ordinances and state laws
relating to building construction, and hereby authorize representatives ofthis
citytoenterupontheabovamentinned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupedlno
against habllities,judgments, costaand expenses which may in anywayaccrue
against old City in roniryuence of granting of this permit.
..
Sigwtun of Applicant/Crntredor Date
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicantorfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
hkxlth and Safety Code .a �No-.Section 25532(.)7
F1 Yes . u .
Will the applicant or future building occupant use equipment or devices
which endt hazardous air contaminants as d.fined by the gay Area Air
Quality Management District?
Yea ❑ No
`Thavc read the hazardous materia'. regoirements under Chapter 6.95 of
the GllfornM Health A Safety Code, Sections 75505, 75533 and 75534. I
understand that lithe building doesnot correctly have a tenant, that it is my
responsibility to notify the occupant ofthe requirements which must be met
prior to issuance of a Certificate of Occupancy.
�. -Mr-20
GREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID .
Date Recei [#
GREASE TRAM' -
SEWERSANITARY•STORM EA 2001717.(Thlssectlon
'. WATr.RHF-ATERW/VENT/FLECTR
a 06 -
ENERGYFEE Y N
PA ID -+ -
+ 'Date Recei t#
+
WATER �" M/712�T(NG
NEWRESIDENTIALPWILSQFI'.
-
TOTAL:
U NG
FEE
- TOTAL: // Ori
7
SEISMIC FEE
ELECTRIC FEE
'QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
-
ALTERORADDTOMECH.
-
AIR HANDLING UNIT (17010,000 CFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID: •
Date - ' Receipt#
SUBTOTAL•
MR HANDLING uNrr fcivaR June am)
DIHAUSTHOOD (w/DUCT)
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
-
HEATING UNIT (TO 100,000 BTU) -
'Date REC'ei f#
HEATING UMT(OVER 100,000 BTI!)
'
' TOTAL:`,
VENTILATION FAN (SINGLE RESID)fd64010EDATE-
x IiKW6.
p q
OCT
- . riT 31%1 90'
,
�jj4(ss�(�' '
-� O!DUE$" '
ISSUED BY: "`�+'� 1''r�••',
BOILER-COMP(3HP OR 100,000 BTU)
BOILER-COMP(OVER 100, 000 BTU),-'�4J
NEW RESIDENTIAL MECH. SQ,FT.
-
Qwner or authorised agent - Date
TOTAL:
OFFICE COPY