20631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -:— USE BALL POINT PEN ONLY
Building Proles Identification PERMITNO.
Building Add/ 20631
no AFFLICAI15NSUR9rrTXE=
CITY OF CUPERTINO-BUILDING DIVISION
ConHador•Nana: LIoNo: APPLICATION /PERMIT V
BUILDING.ELECTRICAI.!'LUMBINGMECHANICAL CATEGORY CONTROr
Architect/Engineer. Lia.No: (.V
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE - ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby albm that l am licensed under provisions of Chapter 9(commenc APPLIANCE3RESIDENIAL JOB DESCRIPTION
IMon 7Dlvisim tthe BuslneaandPro(eaonsCeend my
If...1,1.(un fxor.rd effect.
PANELS
License Clem Lic.N
Date Contractor —UP TO 20DAMPS
ARCHITECTS DECLARATION 201-IODO
o:O I understand my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ee�E Licensed Professional SIGNS ELECTRICAL
In< fli'SI OWNER-BUILDER DECLARATION Spp,C1ALCRiCU1T/M75C
7p, y Ihtmbyaffirm that lame.empt from the Contmdors License law for the
OHfollowing reason.(Section 7MIZ,Business and Prof egions Code:Any city or Fp oountywFkmd mmWre
h requireaapermltlorutru ,alter, deoh,orpair TEMP.METER OR POLE INST.
�L le slrodurepdorm He that
he I Wo.cd pursuant t the provisions
of t e POWER DEVICES
K � file a signed statement That he V Ikensed pursuant to the proWlons of the
Ou, Contractors License Le.(Chapmr9(commenMg with Sedbn7000)of Divi-SVALUA110N OS sion3o(the Buslnessand PrfemionsCode)orthatheisexempitherefromand SWIMMING POOL ELECTRIC O`
the basis for the alleged exemption. Any violation of Section 70315 an OUTLETSSWITCHESFIXTURFS �^1
0 Xle(SM
t(ora permit subjects the applicant too civil penalty of one more than ISO l..-l. o
$ dred owner of thepr. NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
?G owner of the property,or he semployees with wages r !herr sokuHon,w0ldothe wmk and lhestrudure V notlntended or offered(or
7074 Business and Pro(esvims,Code:The Contractors License Law
r3'$ does not apply to an owner of property who Wilda or improve,t herein,and OCC.GROUP RFS.UNITSwho doceauchwork himselforlhrough hbownemployees,providM thatauch ��ac-
Improvements am not intended oro(fered lorsale.If,however,the W L;
ildingor TOTA
Improvementhaold withinoneyearo(compldlon,theowner-W Oderwill have
t rden of proving that he did not bund or improve for purpose orale.). QTy. PLUMBING PERMIT FEE FLOOD2ONE APN
Lj I,as owner of the property,am exclusively contracting with licensed
contractoralomnsHucttlaprojed(Sca70K Businessland ProfessionsCade: PERMITISSUANCE
The Contractor's Limnse Taw does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wild.or improves thereon, and who contract.for such pt,oleces with a
�gLt[e&or(-)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See. B&P C for this reason
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N
Owner '
Date RECEITN
WORKMAN COMPENSATION ceAT10N DECLARATION FO(TURES-PER TRAP SCITOOLTAX Y_ N_
❑1 hereby affirm that I haveemat•mrtl0rne of aconsent
cenifi to opy themo ora RECEIVE N
ceHiflab of Worken'Compewatloninsurance oracertlfled ropy thereof ssec. GAS EA.SYSTEM-]INCAOUTLMS PARK FFE Y N
3800,Leis C.7
Policyp -.BUILDING
Cam an GAS EA.SYSTEM-0OVER Y BUILI3INC DIVISION FEES
Certified copy b heed with
the cid. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certnied copy V filed wIN the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date ReeCl I# 27
RM1lseectlon need lid W completed it the permit H mrone hundred dollars
($101(Emes•.) WATER HEATER W/VEM'/ELLCTR ENERGYFEE Y N •—
I mrtity,that in the performance of the work forwhich this permit is Issued,
1 shall not employ any person in any manner an as;to become aub)ect to the WATER SYSTEM/TREATIN'G
Workers'Compenation Lava of Californh.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Dale Recei f#
Z O NOTICE TO APPLICANT,If,after nuking this Certificate of Exemption,you
should become subject to the Workers Compensation provisionsof the Labor TOTAL:
tl) Code,you=at forthwith comply with such provisions or this permit shall be BU
W > deemed revoked.
a C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebya(firmthal there b a mmtrudion lending agency for the perform- TOTAL: ELECTRIC FEE L
anceof the work for which this permit b blued(Sec.3097,Clv.C.)
V O Lemder's Name PLUMBING FEE -
LL H Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1oerlilythat l have read this appliatlonand state thatlheahovelntarmatlon
1 Iscorrect.I agree to comply with all city and coumtyordinaneea and state laws PERMIT ISSUANCE FEES PAID:
>. W misting to Wilding construction,and hembyauthoriza repreaentativesofthis
f. Z city to enter upon the abovcmentiomd property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to ave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agaWtRabWties,jrdgments, lid expenseswhlch naym.nymy.mmc AIR HANDLING UJNIT(TO 10,000 CFM) SUBTOTAL:
a ns Id city In mnaryue the granting of this pe IL AIR HANDLING MIT(OVER IO,ODOCFM) CONSTRUCTION TAX
goamoof Applicant/Co odor Dale— P70IAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7AR US MATERIALS DISCLOSURE
Will the applicant or future building oaopant store or handle haasrdous HEATING UNIT(ED 100,000 BTT) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
EfraftIl and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU)
Yn ,{+�-,I No
Illtheeppliant or futum Wilding occupant use equipment ordevices VENTILATION (SINGLE RFSID) ISSUAN TE
which emit havardous air contaminants as defined by the Bay Arca Air
Quality Management Distcid7 - BOILER-COMP(3FR'OR 100,000 BTU) 1. 1 1p90
4Yes ❑❑No
hay .ANehaaardml rwteealsmquimmnnbunder Chapter6.95ot BOILER-COMP(OVER 100,000 BTU)
the Olifemia I Iealth&Safety Code,Sections 25505,25533 and 75534. 1 aesrh�
understand that lithe building d..m currently have.tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT awl
prvm u,ihv..m notify the .m.f l of the requircmenU which must be met
prior to Issuppntt o�(Ia'Cer,tlfiate of Occupancy. '
�Ci �n��,✓La..� �/ /9t,) '�k���'''(['�,� �{s,.�` ,�..'
Owner or author)ud add''efit Date TOTAL: ISSUED 0Y:
OFFICE COPY