20890 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BmIdin Project Identification PERMIT NO.
Ouilding Address:
10610 E ES7-hTF5 20890
nes ame: one: A A A
THOMAS sCHACF CITY OF CUPERTINO-BUILDING DIVISION �_► ��0
Contractor's Name: Lie No: APPLICATION /PERMIT
Architect/EngineerLk.N. BUl1DING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL a
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERh9TISSUANCE ❑ ❑ �/I ❑
LICENSED CONTRACTOR'S DECLARATION LTJ
I hereby affirm that l am licensed under provisions of Chapter 9(comrnme- APPLIANCES-RESIDENTIAL JOB DESCRI'HDN
ingwith5eaion7(100)of Division3 ofthe Bus(nessand PmfessionsCode,and my
license Isla full force and effect. PANELS
License Class Lic.N YV
Date Contractor
—IMT02DOA IS
ARCHITECTS DECLARATION 201-1000 AMPS
ce7p7OC I understand my plans shall W used as public records. OVER1000AMPS SQ.I:[,FLOOR AREA 8/SQ.EI.
ZU Lfcenaed Pro(easiorai SIGNSELFLTRICAL
in
�<N OWNER-BUILDER DECLARATION
i.,�2 1 hereby affirm that Is.exempt from the Contractor's License Law for the SPECIAL CIItCU1T/MISC
XO_ following reason.(Smion 7MIS,Business and Professions Code:Any cityor
rZi"'� countywhfch requires a permittemosmaa,alter,improve,demolish,ormIn it TEMP.METER OR TOLE INST.
anystmenue prlorm its issuance,also requlresthe applicant forsuch permit to POWER DEVICES
file a signed statement that he W licensed pursuant to the provisions of the
w fn Contractor'.License Law(Chapter 9(commencing with Section 7000)of Divi-
sion 3 ofthe Business and Professions Code)orthat he is exempt therefrom and VALUATION
�'•.1 the basis for the alleged exemption. Any violation of Seaton 7WIS by any
05 applicant for a permit subjects the applicant to a civil pevltyof not more thin OOTLETSSW[TCHF5HXIVRFS
GL five hundred dollars($500), NEW RESIDENTIAL ELECTR
�n as owner of the property,or my employees with wages as their sole e"Q'FT. STORIES TYPE CONSTRUCTION
c pensati$n,wW clothe work and thestruclure W not ntended or offered for
O sale(Sec.7014,Business and Professions Code:The Contractor's License Law
does not apply to an owner of property who builds or Improves thereat,and
who doessuch work himself orthrough his own employees,provided that such OCC.GROUP RESUNFM
Improvements are not intended oroffered formic.If,however,thebuflding or TOTAL:
improvement is sold within oneyearofcompldioq the owner-builder will have
t rFL
den ofprovfngthat he did notbuild or improve forpurpose ofsale.). QTY, PLUMBING PERMIT FEE OOD ZANE PRN
I,as owner of the property,am exclusively contracting with licensed ► PFRMI7ISSUANCE
contractors to coramact the project(Sec.7044,Business and Professions Code: l is�
The ContraRor's License Law does not apply to an owner a property who
Wilds or Improves thereon,and who contracts for such p(ojets with a ALTER-DRAIN&VENT-WATER ISM
151courts)licensed pursuant to the Contractors License Law. FEE SUMMARY
am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE s C'O !2Qjsi DE Vi�rs
Owner Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECENT N
S ❑I hereby afflrm that I have a certificate of consent to self-iname,or a FIXTURES-PER TRAP l Q.(�' SCHOOL TAX Y_ N_
certificate of Workers'Compensation Insurance ora certified copy thereof(Sec. RECEIPT N
3800,Lab Q GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy N RECENT a
Com any GAS EA.SYSTEM-OVER BUILDING DIVISION FEES
�CertfRed copy 0 hereby furnished.
❑Certified ropy W filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EX.MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectfon need not becompleted ifthepermit isforonehundred dollars SEWFR-SANITARY-STORM FA.200FT. Date Recei t#
($100)or leu.)
I certifythat N the performance ofthe work forwhich this permit is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I shall not employ any person in any manner so u to become subject to the —
Worken'Compensation Laws of California.Date WATER SYSTEM/TREATING PAID
cant
Z Z NO CETOAPPLICANTAl,after making this Certificate of Exemption, NEW RESIDENTIAL PLMB. SQyT. Date Recei t#
55 should become subject to the Workers'Compensation provisions of te Labor
W~ W Code,you must forthwith comply with such provisions or this permit shall be TOTAL:
> deemed revoked. BUILDING FEE
tl p CONSTRUCTION LENDING AGENCY SEISMIC PEE
= Z I hereby affirm that there V a construction lending agency for the perform
an.of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: Z.�CD ELECTRIC FEE
LL O Lender's Name PLUMBING FEE QO
LL F Lender.Athatl QTY. MECHANICAL PERMIT FEE a
O W Iceaifythatlhave rcadthaappliatlonand aatethattheabove Nformation MECHANICAL FEE
G Is corms.I agree to comply with alt city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} fA relating to building construction,and hereby authortze representatives ofthis
F- Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,ju dgments,mks and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga 'I sttpl¢ntx fPQf flog of this permit./TV•M- AIR HANDLING UNIT(OVER 10,000 CFMI CONSTRUCTION TAX
4gnamre of Appaant/ emnaor �DaD EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfvture building occupant store or handle hazardous HEATING UNIT(TC)100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 933 and the Date ReCel t# ty
HealthYes Safety Code ion 75532(a)? HEATING UNIT(OVER 100,000 BTU) CO
TOTAL: mit
❑ Yes a any
Will the applicant$ furore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �G UA I�EDATE
which emit hazardous air contaminants as defined by the Bay Area Air MLL
• Quality Management District? BOILER-COMP C311P OR 100,000 BTU)
4have reYes azar $ad the Nmaterials requirements nts and and 255M.15 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,75533 and 75534.I
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI'.
responsibility to notify the occupant of the requirements which must be met Ct,I �y rijpp�jpfT
prior I,issu Certificat
Owner or authorima agent
TOTAL: ISSUED BY:
OFFICE COPY