20845 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ca tdemification - PERMITNO.
Building Address: - 20845
6 00 iS P-0JO/o
wnara11.me. arWqPhone A A
CITY OF CUPERTINO-BUILDING DIVISION �' 2
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Mh C..Ate °' 'an1ef LIc.N. APPLICATION / PERMIT
UfLDINGELECTRICALML BINGMECIiAMCAL CATEGORY CONTROL It
Architect/Engines Lk.Na B
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: _
PERMIT ISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ion7OOMtlamlkensedheBusiovandPffesMms9(e,andm- APPLIANCESRESIDENRAL JOB DPSCRR'I'ION
(n ease I .full force of d afelon3o(the Businenaand Profndons Code,and my
license le In full force and affect, PANELS ;Q �1 `
License Cl.as Lie.11 74CS/
Date Contractor
ARCHITECTS DECLARATION 1-1000 PS
m0 Z I understand my plans shall be used as public records VER 1 AM SQ.FT.FLOOR AREA S/SQ.FT.
COC
U Licensed Professional 5 LECTRICA
el¢} ° OWNER-BUILDER DECLARATION LCIR M1SC
7 t'YAa Iherebyalfirm that l am exempt from the Contractor's License Law for the
following reason.(Section 90115,Business and Profess me,Code:Any city or
F t'�
county which requlresapermitt oconatmct,ilter,improve,demolish,okpai P.M POLE INSf.
anyetructure poor t°Ib lsvuaoee,alao requlreatheappecent forauch pefile a signed statement that he b licensed pursuant to the provisionsContractor'Lt..Law(Chapter9(mmmenengwithSectl°n9000) GPOOL .ECTRICion3ofthe Buslnesaand PmfessbmCode)or that he b exempt[herefro VALUATION
thebasis for the alleged exemption. Any violation of Section]0115 app Heart fora permitsubjects the applicant too civil penalty ofna on OU7LETSSW[TC E ES
plCyy livrres�hunr�dred Bo�lters(5500). NEW R DENTDMn s. SQ.F
(d 7 L!! s Owr r of the pmperty,or my employees with wages as their so f. SLOW ES TYPE CONSTRUCTION
k 6 compcmati°n,will do the workand the structure is not intended or olfe
5 ❑ sale(Sec.9044,Business and Professions Code:The Contractor's License law
�$$ does not apply to an owner of property who Wilds or improves thereon,and /
who does such work himself orthrough his own employees,provided that such OCC GROUT' RFS.UNITS
bnpm 'nonts are not Intended or offered sale.If,however,the be llding or IOTA
improvement bsold withlnoneyear°fcompletlon,the owner-budderwlll have
th,s.pnHen of proving that he did not Wild or improve for purpose ofsaleJ. QTY, PL BING PERMIT FEE F1.00D 11) APN
lJ L as owner of the property,am exclusively contracting with limnedPERMIT ISSUA E
contrack rs to corsstmn the project(Sec.9044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such p(ojects with a
'asactor(-)licensed pursuant to the Contractors License Law. FEE SUMMARY
em
and B&P C for his reason BACK FLOW PROTLCT.DEVICE
or Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATI N DECLAR ON RECEI T M
❑{.hereby affirm that I have a artiBcate of consent to self-insure,or a FIXTURES PER TRAP SCITOOL TAX Y N_
mdifiesteof Work m'Compersatimlna mnmoracandledmpythereof(Sec. RECEBrfa
3800,Lab C.) GAS EA.SYSTEM-I INC.4 OUTLETS PARK FEE Y N
Policy p RECEIIrI'M
Com oy GAS EA.SYSTEM-OVER 4(EA)CCamfled copy b hereby furnished. BUILDING DIVISION FEES
❑Candied copy b filed with the city inspection division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Chissedionneednotbecompteted lfthepermit It foram hundred dollars SEWER-SANITARY-STORM EA.200FT. Date RC i t#
(51I onAifess.) WATER HEATER W/VENC/ELECTR ENERGYFEE Y N
I ll am employ
hi zany person in an the work sa as to become
Permit is to ti , —
I shag not employ any pennon in any manner ao as to become subject to the
Workers'Compensation Iowa of California.lifornia. WATER SYSTEM/TREATING.Date PARD
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB, SQ}7, Date Revel t#
Hshould becomesubject to the W°rkers'Compersatlon provblors ofthe Labor
N Code,you must forthwith comply with such provisions orthb TOTAL:permit shall be W BUILDING FEE> deemed revoked.
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Ihereby affirrethat there Is a conatmcuon lending agency for the perform TOTAL: ELECTRIC FEE
once of the work for which this permit Is Issued(Sec 309],Civ.C.) a
U O tenders Name PLUMBING FEE
1L I— tender'sAddreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenlfythatlhavereadthbappli-d nandnatethattheabovelnformation
M bcnrrad.Iagreeto comply with all city and county ordinances and date laws PERMTTISSUANCE FEES PAID:
} N relating to building conamrction,and hcmbyauthoAmmpmwrtativesofthts
Z cityto enterupon the abovnmentbned Propertyfor Wpenbnpurpoun. ALTERORADDTOMECH.
C.1 — (We)agree to save,indemnify an d keep harmleas the City of Cupertino Date Receipt#
against liabilities.jrdgmenta,cousand expemai,whlch mayln anywayamue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
against sold City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signatureof ApplHAZARDOUSor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant orfuture building occupant store or handle harardom HEATING UNIT CIO 100,0D0 BTU)
material as defined by the Cu ertino Munidp
F—IY a l Code,Chapter 9.12 and the Date �Recei t#
I ad Code. Non25532(a)9 HEATING UNIT(OVER 100,000 BTU) TOTAL-
Will the applies ntorfuturebuilding occupant use equipment or devices VENTILATION FAN(SINGLE R- III F¢SSCJAN(;�ggTii7
which emit havrdom a4 cont minant-aa defined by the Boy Area Air
uJ
Quality Management Dislo BORER-COMP AIN OR IW OW BTU)
TTI Ycs o
have read the hors us materials requirements under Chapter 6.95 of BOfLGA-COMP(OVER 100,000 Bi U) .r-'�hf C4 rq(+PTtIDD
the Calilorett health&Safety Code,Sections 25505,2SU3 and 15534.1
understand that lfthe Wilding does not currently have a tenant,that it is my NEWRESIDENTIALMECH.-SQ
responsibility to notify the occupant of the requimments which swat Ee met
*Pnorlonauanceof.Ceftiflott e of OccupancyBe
eror oared agent Da 4a
TOTAL ISS
OFFICE COPY