20917APPLICANT TO FILL IN INFORMATION WITHIN RED I HJFR _ ucF wril I Dr%IPIT DCIV Akll V
Building Proect Identification __-- -- —
eullding Addmse:
nlrB iIM:
—•�_��
PERMIT NO.
20917
use:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
c° Inn°`°Name:
��
BULLDINGE.ECTRICALGEC
PLUMBINMHAMCAL
I a le No
CATEGORY
CONTROL #
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add..
I'ERh11TISSUANCE
❑ ❑ ❑
LICENSED CONTRACFOR'S DE RATION
I hereby affirmthat l am Bcensed under PrwLdons ofChapter9(mmenm
ingwith Se On7000)of DiWslon3ofthe Businsasand ProfesNons Code, and my
Iirenm is in 1 and erten. ^^
L=Cb _ Lic Mdrl
Date ntnctor
APPLIANCES -RESIDENTIAL
-
PANELS
JOB DESCRIPTION
ARCHITECTS DECLA N
Iunderstand my plane shag be used As public record&
V Irl (
201-1000 AMPS
OVERIOOOAMPS'
SIGN 5 ELECTRICAL
SPECIAL CIRCUIT/MISC T E R
r TEMP. METER ORPOLE INSf,Ow
x�
_ O ,
POWER DEVICES
SWIMMING POOL ELECTRIC VALUATION
OUILETSSNTTCIiESFIXTURES -
NEW RESIDENTIAL ELECTR _SQFT. STORIES TYPE CONSTRUCTION
'
OCC. GROUP RES. UNITS
TOTAL:
QTY, PLUMBING PERMIT FEE FT.WDZONE ppry
I'FRMrr ISSUANCE _Qy
ALTER -DRAIN& VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE FEE SUMMARY
i Licensed Profewlorul
T OWNER -BUILDER DECLARATION
a I hembJeafRrrothat l am exempt from the Contractor`s License Law for the
1 fotrity hichre uicasaon7(A1tocenilnnsand Pinprove, Code:Anydty or
17 foil Ing &son. Seca permetomvltun, old Prol.i n Code: Anycity
anyrtmr.Wrc pdoroa Ib baaarmq aborcqulrntheappBcent for such pemdt 1°
J Ble a signed statement that Is b Ikeneed pursuant to the provblols of the
Conlnnor'e License law (Chapter 9 (mmmindng with Section 7000) of III I. euelneuand liofemlaru COde)orthat heb exempt there(romand
the lusts for the alleged exem)atlan. Any viotatlon o(Sectlon 7e11.5 by any
appilnno(ora permit eubjenslhc applicant loo civil penalty o(nm moretlun
(less hundred dolbn (5500).
�I, as owner of the property, or my employee with wages a° Jr sole
compeneaHory wllldoohe work andthe swclurc b tot intended or ofI red for
sale (Sec. 704#, BusNess and Profeesbre Cede: The CononctaYe Llcerue law
doe not apply to an owner of property who W IWs or improve IhercoR and
whodceesuchworkhimselforthrough hlsownemplga; provided that ouch
improvement°arenot Intended or r.fc.r (tesla. If, however, ohebulldingor
improvemem Lvaold wllhlnor,eyearo(compinion,lheowner-buBderwlll have
ttlgJ;urdenofpmNng that M didnot bulldorlmprove (r purpOseafsaleJ.
IUJ L ore owner of the property, am °xcloeively m aroning with licensed
contractors to ninuit the project (Sec.70N, Ruelnm and Profa m Code:
The Contractees License ]aw does not apply to an owner of property who
builds or Improve thereon, and who comrade for such p(ojacts with °
ro anor(s)Icensed pursuant to the ConlnctoYs License Law.
I am exempt under Sec B & P C for this reason
Owner Uate
WORKMAN COMPENSATION DECLARATION
hereby allrm that I have a cattiness or consent to self-Inwre, or a
re fiats ofWorkea Compe=tlon Lsuranmoracertlfledcopythemof(Sec,
polky 03800,T,C.)
Y
DRAINS FLOOR ROOF, AREA, GOND.
FTKTURM � TR'
SANITARY Y N
RECEIT I
SCHOOL TAX Y N
RECEI'fN
GAS EA. SYSTEM -1 INCA OUTLE'T'S �. D
PARK FFE Y N
RECEIPT*
Com
Com
Com ray
copy is hereby fumlehed.
CAS EA. SYSTEM.OVER 4(EA)
BUILDING DIVISION FEES
[_]Cenlfied copy lefiled with the city bupection division.
CREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TNsaecHonneed not becompleted iflhe parental
(9100)orless.) tone hunertd dollars
GREASE TRAP
PAID
Date Recel t#
SEWER -SANITARY -STORM EA. 200F7.
WATER HEATER W/VFNT/ELECTR
ENERGY FEE Y N
PAID
Date Recei t#
'
I artirythat In the Performance ofthework for which this permit is bsued,
I shall not employ any person In any manner soore to become subject t° the
Workers' Compensation laws of California. Date
Applicant
WATER SYSTEM/TREATING
NOTICE TO APPLICANT: If, after making lhi°Cenifi-m of Exemption, you
should become subject to the Workers' CompewtlOn provisions Of the Labor
Code, you must forthwith comply with such provisions or thismpermit shall be
deeed revoked.
CONSTRUCTION LENDING AGENCY
them iamwo I.usolendingagenq for the perform
I hereby work for
anceaflheworkfor whlchlhbpemdob owed (Sec. 3097, Civ. C.)
Lender`s Name
Lanares Adhat1
Im"t.1oagrea vcmply with all
recoingtobgreto comply with aldtyandcouhorLAA pm,mtnd nateiasva
yordinnces andLaws
relating to building cormtruMon, and hereby authorlu rcpresentativcs o(Ihb
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d kap barrel. the Clty of Cupertino
agaitutllabilltie,judgments,con°and°xpen°ewhlchmaylnanywayaarue
against said City in Consequence of the granting of this permit.
NEWRFSIDENTIALPLMB. SQ.F'r.
TOTAL:
TOTAL, M
BUILDING
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMHISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
-
ALTERORADDTOMECH.
AIR HANDLING UNIT(r010,030 CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT(OVER I QODO CFM)
CONSTRUCTION TAX
Signature of Appllcant/Conoxan, Data
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllantorfutumbufldingar pantamaorhanelch.,douaNIT(TO)OD,000
material.. defined by the Cupertino Municipal Code, Chapter 9.12, and the
Iie❑slt Yea Safety Cods SeNloon 25532(a)7
Ye
Will the appliantor tum building occupant use equipment or devicesN
which enut hassrdou°air mntaminantsas defined by the Bay Are. Air
Quality Management DIsM
4Yea o
OOD(W/DUCT)
CONSTRUCTION TAX PAID:
BTU)
Date RCCeI (#
T(OVFR100,0WBTU)
TOTAL:
'V
I-AAN STAID)
ISSLIANC&DATE
E �6BYi66-dd•1r!'
P OHP OR 100,0(p BTLD
19TAL:
bavareadthe haxr u°material, requirements under Chapter6.95ofP(OVER100,000
the Ca llfornia Health & Safety Code, Sen loco 25505,25533 and 15534, 1
understand that if the building does not currently have a tenant that It b myMALMECH.
responsibility to Oily the occupant of the requirements which must be met
prior onceof.Cenif O anry. ^j 4
7�Qv
n j9(�O
,l (] "'(, 1
City of CHnertlpn
'
BY: D Vc.L
BTU)
SQFT
net or out ised ag rat Date
TOTAL: ISSUED
OFFICE COPY