20820APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ert Identification ss:
Build Ing Addre
lO D 13�✓o,
Z O U 4'O PERMIT NO. 4�
G 82
ere ams: one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
B(1ILDING-ELECTRICALPLUMBINGMECHAMCAL
Con '.Nam: Lic.No:
T C y
CATEGORY
CONTROL N
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address7
BLDU
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapmr9(commme
Ingwlth Sedton7ODD)of DlWston3ofthe Budmnsand PmfeWom Codga dmy
Ilcensetslnfu fmceaedeffed,
LcenseC _ LcN
Date Contractor GuPfLT/a!G C ZC ,
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Profenlor al
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contradar'a License Iaw for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
.elywhich require, a permit to construct, alter, Improve, demolish,orreper
any structure prtortolts issuance,alsorequirm theappliam forsuch permit to
ilk a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter9 (commencing with Section 7000)of Divi-
sion3 of the Business and Professions Code) arthat heb exempt ihenfromwd
the basis for the alleged exemption. Any violation of Section 7031.5 by any
na on than
applicant for a permit subjects the applicant to a civil penalty dm
fiundred dollars ($500).
6NEW
I, as owner of the property, or my employees with wages as their sok
compensation,w0ldothe work, andthestructure Is not intended or offered for
sale (Sec 7064, Business and Professions Code: The Conmictoe. License Law
don not apply to an owner of property who builds or Improves thereory and
who doessuch work hlmseBor through his own employees, provided that such
improvements arc not Intended oroffered forsak. If, howevegthe bulldlegor
improvementhwldwithlnoneyurofcampldloktheowner-bu lderwillhave
tfajjuiden ofproving that he did nabulldorlmproveforpurposcefeale.).
" L as owner of the property, am exclusively contracting with licensed
contractors to construct the pm*d (Sec 7014, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves theres, and who contracts; for such p(o)eds with a
coR([+ctor(.) licensed pursuant to the Contndox. License Law.
I_J I am exempt under Sac. B & P C for this reason
APPLIANCES-RESIDENTfAL
J BDESCRII'IION
PANELS
701-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
'
$M. FT.
SIGNS ELECTRICAL
SPEGULCRCUIT/MIST
TEMP MEM ORPOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
&1) UILETSS4ITCHESFIXEUR
VALUATION
RESIDENTIAL ELECTR SQFr.
ES
TYPE CONSTRICTION
TOTAL: Q
PLUMBING PERMIT FEE
C.GR
RES. UNITS
QTY,
PERMIT ISSUANCE
ALTER -DRAIN & VENT,- WATER ears)
FTGODZDNE
APN
FEE SUMMARY
- BACK FLOW PROTECT. DEVICE
DRAINS FLOOR AREA, COND. ROOF, AR
FIXIlIRES PER TRAP
SANITARY Y_ N_
RECEIVE N
Owner Date
WORKMAN COMPENSATION DECLARATION
[:]I hereby affirm that I have a mrtifiate of consent to self -Insure, ora
certifimte�joof)JWork WcCompemationlmumnmmacertifWmpythenaf(Sec.
1'ollry pbl-C 44oi T3
SCHOOLTAX Y_ N_
RFGEI NN
GAS FA.SYSTEM-1 WC.40UILEIS
PARK FEE Y N
RECEIPT It
-
GAS. EA. SYSIM.OVER 4(EA)
Com an .
Y
BUILDING DIVISION FEES
Certified copy Is hercbyth the city
Certified copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
IThl.section need not be completed if the permit V for one hundred dollars
(SI00)mless.)
I certifythat N the perforrunce of the work for which this permit is Issued,
1 shall not employ any perws In any manner w u to became subject to the
Workers' Compensation laws of GIIlornia. Date
NOTICE
NOTICE TO APPLICANT: If, after making this CsrtlBeats of Exemption, you
should become subject to the Wurkars' Compereation pmvidom of the Labor
Code, you must forthwith comply with such provialons or this permit shall be
deemed rooked.
CONSTRUCTION LENDING AGENCY
Ihembyafflm that then is a construction lending agency forthe perform-
ance of the work far which this permit I. bored (Sec. 3097, Civ. C.)
Lender's Name
Lend.e.Address
I celtilythatl have madthd applicationand date thattheabove Information
is correct. I dgree to comply with all city and county ordinances and date laws
relating tobuilding construction, and hereby authorize representatives of thio
city to enter upon the above-mentioned property for inspection purposes,
agree to save, Indemnify an d kes harmless the City of Cupertino
aWt bNtiee, judgments, sande se.w khmaylnanywayaccme
against Id Cl�ln conseque o(th tin t emnit
num of Appant on d Date
HAZARDOUS MATE ALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrdoua
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
HrAthand SafetyCade Soction75537(a)7
Yes o
qilltheappliantafu re building occupant use equipment or device.
which emit hamrdous Ircontamimntsasdefinedbythe Bay Area Air
Quality Management Dis ci7
4Yes No
have mad the: ass ou. materials requirementsundcr Chapter6.95 of
the California health & Safety Code, Sections 25505,25S33 and 75534.1
.und that itihe building does not currently have a tenant, that It u my
nslbB to notify theoc pant emqul me whkh must berM
riorto anrndaCe Ifi sof panty.
14
or aulhodred agent Data
'
GREABEnNDUSTRL WASTE INTER CEPTOR
PLANCHECK FEE
PAID
Date Rece! t#
GREASE7RAP
SEWER -SANITARY -STORM EA pDFI.
WATER HEATER W/VENT/EL[CTR
ENERGY FEE Y N —
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB._-SQ}T.
TOTAL:
NG
FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
PLUMBING FEE
MECHANICALFEE
FEES PAID:
ALTERORADDTOMECH.
Date Rece1 t#
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX'
EXHAUST HOOD M/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,0DO BTU)
Date Recei t#
HEATING UNIT(OVER 100,00) BTU)
TOTAL:
'10 rco
t
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
V
.1
i+;L rj ly� V
.
ISSUED BY: VVVI(L_�IXM1 B{'q•�YrlLKaaa
BORER -COMP OHI' OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEWRESIDFNIIALMECH. SQ.rr
TOTAL:
OFFICE COPY