20966APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: - ^ 1-
PIRMITNO.
.. -. 20966
score ante: - - one:
eOaJt etio - a 6`aZ"jV6/?
_
CITY OF CUPERTINO-BUILDING DIVISION,
APPLICATION I PERMIT
BUILDINGELECTWCALMUMBING-MFCHAMCAL
A
Contractor's Name: - ` Lie. No:
• 4 —
CATEGORY
ONTROL N
Architect/Engineec.
S E v BSA �C,YBUILDING
QTY • ELECTRIC PERMIT PEE
PERMIT INFO
Adders:
PERMIT ISSUANCE-
❑ ❑ _ ❑
- LICENSED CONTRACTOR'S DECLARATION
I Mrebyaffirm that l am licensed under provisions of Chapter 9 (counamon,
afthe Butlnessand Pro/assionsCade,and my
Inlicense 1.SectionU11 f000)otd effect.
Lireb Iny�11 ft, d effect
License Cb:6�Q•ic, p- 3 a4
Date
Date Contactor ,,A,
ARCH TECH DECLARATION
I n y pots s 11 be uaed u public records
CCCCCC....//////
Licensed Pmfx&I.AA
OWNER -BUILDER DECLARATIONcPFrIAL
Ihereby affimnthat l am exempt fromthe Contractor'sLicenseLawforthe
followingmason.(Section 7031.5, Business and Professors Code: Any city or
countywhichmquimsapermittoc nmtmMalteglmprove,de.1i.h,orrepair
anystructurs priortolb Issuance, also requlreathe applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Comramor's License Law (Chapter 9(commencing with Section 7000) of Divi-
s1on3o(the B.sN,.andProfemloru Code)orthatheisexempttherefromaM
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant ora permit subjects the applicant to a civil penalty of not morethen
five, hundred
❑ I, as owner of the property, or my employees with wages r thele sole
compensation, wBldotMwork and Professionstructure Th wtntendeda coffered w
Code: Contractors thence Law
dosale renSec apply fluto ainess an owner of property
docs.&apply rkhi ifwth pedy SO Wilds or Improves thence, and
who doessuchwork M1lmeelforlhrough hiaownemployees,provided that such
Improvements are not Intended oraffered for who. If, however, thebullding or
Improvement bsold within oneyearofcompletloktheowner-bullderwill have
thlE.Itunienofproving that he did con build orimprove for purpose ofsate.).
Lf L as owner of the property, am exclusively contracting with limosed
contractors to construct the project (Sec 7044, Business and Prof..[.. Cade: The Contractor's License law does not apply to an owner of property who
Wild. or Imp. thereon, sad who contracts for such pno)ecb with a
gIdE. me(.) licensed pursuant to the Contractor's License Law.
Lec f I am exempt under SB k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
�
PANELS
PANQS
i'S -
201-1000AMPS
- OVER I ODO AMPS
SQ. Fr. FLOOR AREA
- -
-
$/SQ. FT.
.' -
SIGNSELECTRICAL
CRtCUIT/h(75C
TEMP, METER OR POLE INS!.
POWER DEVICES
SWIMMING POOL ELECTRIC at
OUTLETSSWITCHESFIXTUR[S
- VALUATION _
-
NEW RESIDENTIAL ELECIR - .FT,
RIES
a
TYPE CONSTRUCTION
•I OTAL:
QTY, PLUMBING PERMIT FE
OCC.GROUP
..
RFS. UNITS
HOOD ZONE
-
APN
PERMIT ISgUgNCE
ALTER -DRAW k VENT- WATER (FN
FEE SUMMARY'
BACK FLOW PROTECT. DEVICE
'
DRAINS FLOOR ROOF, AREA, COND.
F'IX?'URES PER TRAP
SANITARY Y N_
RECEIaPp -
Owner - Date
WORKMAN COMPENSATION DECLARATION
❑. hereby affirm that 1 have a certitirate of consent to eegdnwrc, ora
certl(Icate ofWorken'Comperoatlon lnsuranci orecertitod copythereof (Sec.
3800, Lib CJ
SCHOOL TAX Y N
��. i -
GAS EA. SYSTEM -1 INCA OUTLErg
PARK FEE Y N #
CAS EA. SYST[7.1.OVER t (PA)
Cam any
BUILDING DIVISION FEES
[�CPolicyertlfled copy b hercbyth the cid.
j�Cerlificd wpybfiled with the city inspection division.
]r CERTIFICATE OF IDEMPr1ON FROM WORKERS'
COMPENSATION INSURANCE
(fhb section need one M completed I(tM permit o for one hundreddoltam
(SIDD),olea.)
1 mrify that m the performance of the work forwhich this permit is lusted,
I shall not employ any person In any runner so as to become subject to the
Workers' Compensation Lswsof California, Date
Applicant
NOTICETO APPLICANT: B, seer making this Certificate of Exemptlan, you
should become subject to the Worker' Compensation provblmu of the Labor
Code, you =at forthwith comply with ouch provisions or this permit shall be
deemed mocked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there is a construction lending agency for the perfomt
ante ofthe work for which this permit is issued(Sec. 3097, Civ. C.)
Iandere Name
iander'.Adder. -
I ceddythatl have mad thlsappBcadonand eat ethatthe above Irfomvtion
omrnect. Idgmeto comply with all cityand county ordinances and state laws
relating to building construction, and hereby authorLm representatives of this
city to enter upon the above-mentioned property for Inspection purposes
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against habllBks,judgments, metsand expenses which may in any wayacarue
gains a tylnron ence of the granting& this permit.
GRFASE/INDUSTRE WASTE INTERCEPTOR
PLANCHECK FEE
PAID'
Date RCCet t#
'
GREASE TRAP
SEWR&SAMTARY-STORM PA. 2WFT,
WATIB2HEATERW/VEM/LLLCTR
ENERGY FEE Y! N
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
BUILDING
.. -
SEISMIC FEE
TOTAL:
ELECTRIC FEE
ELECTRIC EEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEB
_
PERMIT ISSUANCE
FEES p�
—J -II
Date Recel t#
ALTERORADDTOMECH.
AIR HANDLING UNIT (10, 10,000 CFM)
SUBTOTAL:
MR HANDLING UNIT OVER IU,000CFM)
CONSTRUCTION TAX
-SIBIVITureof Applicant/Contractor Dae
HAZARDOUS MATERIALS DISCLOSURE
Will theapplice,t or Wure building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
Iiaxlth and Safety Code pion 255320)?
r-1Y.LNo
Will the applicant or future building occupant use equipment or devices
which emit haurdous air metaMnants as defined by the Bay Area Air
Quality Management District?
4Yes he No
haiforeadte.Ith&Safety requirements
the California Ylealih&Safety Code, Sections 75505, 75533 and 25.Sb.I
a rad erste rad that if the building docs me currently have a tenant, that it b my
nspo iblllty to notify the tof the requlrerrenrswhich mustWmM
prior bsuanceof rtl a IOavpa /
Z/
EXHAUST HODD(W/DUCT) _
CONSTRUCTION TAX PAID:
HEATING UMT(T0100,000 BTU)
-
Date Receipt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
_
VFNDLATION FAN (SINGLE RESID)
�.^,.,,,�s}}��,,
NCE DATE
,
T[
S•
,
D��anl
1
ISSUED BY:
BORER -COMP (3FB'OR 100,000 BTU)
BOILER.COMP(OV�2100,000B1n
NEW RESIDENTIAL MECH. SQ.FT.,
orauthmiudagenq Date
'
,
TOTAL:
OFFICE COPY '