20993 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdenHllatlon - '�5 PERF0TN0.
Building Address: 20993
S W - 19,69-3
e I Phone: A p
CITY OF CUPERTINO-BUILDING DIVISION
c N°: APPLICATION / PERMIT
Am tett/Engineer.
9BTJILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL#
Lk.No:
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PrRMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ion7 )ofDtvlken3ofthesedi er provisions ustnemandPmfes )=eC(convnenc- MPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth&Rion 70111))ol Dl affect ofthe Businessand Pm(nsionacode,and my
license ICiis fu'a d affect PANELS
L[can CU Lic.p
nate Contactors
ARCHITECTS DECLARATION �Q—� 281'1000 AMT'S
7 I understand my plans shall be ua ci u public moods. OVER 1001 AMPS SQ.Fr.FLOOR AREA $/SQ.Ff.
O
z� Licensed Professional SIGNSELECTRICAL
6 ° OWNER-BUILDER DECLARATION
Z O cm:CIAl CIRCUIT/MLSC
i., / 1herebyafRrenthat lam exempt from the Contmdorb License Law for the
following reason.(Section 7031.5,Business and Professions Code:An or '
ALF. countywhich requires a permit to ounatmct,alter,Improve,demolish,Any
TEMP.METER OR POLE INST.
��❑ anyatrvdureprbrto lta Issuance,alsorequirestheappllantforsuchpimetto
3, file a signed statement that he is licensed puauant to the provisions of the LOWER DEVICES
Ow Contractor,License Law(Chapter 9(commenMg with Section 7")of Divi. SWIMhONG POOL ELECTRIC
O shc03.fthe Business and ProfessionsCode)orthat he b eaempitherefromand VALUATION
F' S the bash for the alleged exemption. Any violation of Section 7031.5by any
65 applicant fora permit subjects the applicant to.civil penalty anot more than OUTLETSSWITCHESHXTURES l Oct
five hundred dollars(500). NEW RESIDENTIAL ELECTR
F11,as owner of the property,or my employees with wages as their sole SQ.E7. STORIES TYPE CONSTRUCTION
#enation,will dothe work and thestructure is not intended or offeredfor
� p sale(Sec.7044,Buslnessand Professions Code:The Contractofs License Law
$$ does not apply to an owner of property who Wilds or improves thereon,and
who doessuchwork htmself°rthrough hisownemployee,provided thatsuch OCC.GROUP RFS.UNITS
Improvements are not Intended oroffered for sale.18 however,thebuilding or TOTAL:
Improvement h sold within oneyearofcompletion,the owner-builderwill have
t rden of proving that he did not Wild or improve for purpose ofsale.). QTY PLUM IN R IT FEE FLOOD ZONE APN
Lj 4 as owner of the property,am exclusively contracting-an licensed PERMIT LSSUAN
contadors to construct the Project(Sm 7044,Business and Professions Code:
The Contadorb License Law does not apply to an owner of property who AL -DRAIN k AM
or improves thereon, and who contracts for such pi jects with a
gIlt[admr(s)licensed purauanttothe Comrador's License Law. BAIX WPRO .D FEE SUMMARY
c l am exempt under Sec. B h P C for this reason
IT�FDP FEES-
Owner DRAIN F,AREA, TND. SANITARY Y N=
lit Date RECEIPT
p
WORKMAN COMPENSATION DECLARATION SCITOOL TA% Y_ N
hereby a((Irm that[have a certifuate of consent to self-inwre,ora
certificate of Workers'Compensation Imairs ce ora certified copy thereof(Sec. RECFR'T N
3800,LabQ GAS EA. -1 INCAO PARK FEE Y N
Pdiry Y RECEB'r ia
Company / G EA.SYSTEM-0VE B UIL DING D I VISION FE IS
❑Cert a copy h hcrcbythe city
inspection division. EF GREASE/INDUSTRLW R PLANCHECK FEE
� rtified copybflled withh tthe ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissection need nor becompleted ifthepermdt hforons hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Retmi t#
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I reat la rtlfyththe performanre°(the work for wMch this permit Is ivwed,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws m Gufomia. Date
O Z Applicant PAID
Z O NOTICETO APPLICANT:LL after making thisCertlflatr.f Fa,.p,.,you NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Fshould berome subject to the Workers-Compensation provisions of the Labor
W Code,you at forthwith comply withsuch provisions or thls permit shall be TOTAL:
W > deemed revoked. —BUILDING FEE 0 D
CL g] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hambyaffirmthat there b a construction lending agency for the pedortn :
0 anm ofthe workforwhichthb h permit isnued(Sec.3097,Civ.C.) TOTALELECTRIC FEE
(,) _ I<nders Name PLUMBING FEE
LL F Lendrr's Address QTY. MECHANICAL PERMIT FEE
O W Icartilythat l haveread thin appikationanci statethattheabovetfienrolion MECHANICAL FEE
S 6comecc.I agree to comply with all city and county ordinances and state laws PERMIT'LSSUANCE FEES PAID:
N relating to building construction and hereby authortu representative of thiWALT�ORADDTOMECH Z city to enter upon the above-mentioned property for Inspection pu rpowsPRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of CupeDate Receipt#
ga gllabIlitles'jodgment,coet a dexpensea IchmaylnanywayaceHANDLING UNIT 10,000 CFM) SUBTOTAL:
ag sold Cisee a tin Is permit
—s
IiANDLINGIINH(OVERlO,WOCFM) CONSTRUCTION TAX
Slgnsmre of AppBcant/ ontrad r DataAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBant or future Wilding occupant store or handle hazardoTING UNIT 100,000 BTU)
material as defined by the Cu no Municipal Code,Chapter 93Z and tDate Reeei t# ?
IiF❑YC9d SafetyCodr No n 25532(a)7 TING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant.rfuture building occupant use equipment or devicILATION FAN(SINGLE RESID) ISSUANCE DATE
which emlthaement elrcont vnts as defined bythe Bay Ares AlrQ3ality Ma�agcment Dist useER-COMP PHP OR 100,000 BTU) ���
4 Yes ohave read the bozo terlals requ lrements under Chapter 6.95 ER-COMP(OVER 100,000 BHU)the California Health k Safety Code,Sections 25505,25533and25534.I
understand that if the buildingd not currently have a tenant,that it b RESIDENIALMECH. SQ.FTespovlbility to ndi(y the occvpan (that imments wh ich must be mpr' t Lssua�fl q }oyjpccupaS9u f % Y� a Cf rIIDnTFIRQ V
ncr ora thorlred agent pate
TOTAL: ISSUED BY:
f OFFICE COPY