20691 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification _ PERMIT NO.
Buudi%Addmsa: - . 20691
'
n o 8rrle: one:
CITY OF CUPERTINO-BUILDING DIVISION -
Contract r.N.mr. - ar LIc.Nee APPLICATION /PERMIT
S —�
MOSS BUILDING-ELECTRICALPLUMBINC-MFCIiANICAL CATEGORY - CONTROL#
Ar tett/Engineer. �L
LN..• _ BUILDING PERMIT INFO
QTY ELECTRIC PERMIT' FEE
Aaarea,: rEehErlssuANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirrothat l am licensed under provisions of Chapter 9 fiamenneu, APPLIANCESRESIDENLIALlngwitJOB DESC ON
It...IS in full Illi)of d effect fthe0uelnesaandProfesslonsCode,end my - A _
License
Is In s force d effect. ' PANELS
License Class G Llc.# O a SJ I
Date�C HITEC r
CHITECTSDECLARATION "'
00 AMP
u❑�❑u�++
X00 I understand my plans shag OVER
be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
-E�
Licensed Professional SIGNS ELECTRICAL: _
OWNER-BUILDER DECLARATION
SPECIALCIRCUIT/MISC. .
02 owingIle.reaxermfhatlamexemptfromthed Professions
Code:Lw fort he
following reason.(Section 7071:5,Business and Professions Code:Any city or
rEl county which requires a permit to construct,alter,Improve,demolish,or repair TEMP.MmiravOLYAST.
a anystmc mpriortoiUs uame,alsomquimstheapplluntfwsuchpermitto POWER DEVI
U file a signed statement that he V licensed pursuant to the provisions of the
Contmetori License Law(Chapter 9(commencing with Section 7000)of Divi.
30 alpn3p(the Business and Pro esslonsCode)or that heb exempt therefrorand SWIMMING EL VALUATION
Q the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSW[TCI IF.SFI
appbcant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars(SM. STORIES TYPE CONSTRUCTION
R ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIA TR .Fr. -
compensation,will dothe work and the structure le not intended or offered for '
HO sale(Sec.70K Boatman and Professions Code:The Contractors License Law
3$ does not apply to an owner of property who Wilds or improve thereon,and OCC.GROUP RFS.UNITS
who does such work himself or through his own employees,provided that such
improvements are not intended proffered for sale.If,howevep the building or TOTAL: '
i provementbwldwlthlnoneyearofcompletlon.theowner-buBderwillhave
tliLIurden of proving that he did not build or improve for purpose of sale.). QTY, PLUM$I I FEE, FLOOD ZONE APN
u1,as owner of the property,am exclusively contracting with Bonnard PERMIT ISSUANCE q
contractors to construct the project(Sec.7094,Business and Professions Code:The
(�(/
The Contractor's License,
e Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improve thereon,and who contracts for such In e)Ccts with a - FEE SUMMARY
cj5actor(s)Bnsed pursuant to the Contractor's License Law. RACK FLAW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEE'r#
WORKMAN COMPENSATION DECLARATION
❑T hereby affirm that I have a our iffute of consent to self-inwreFIXTURES.PER TRAP,or _ SCHOOL TAX Y N
certificate ofWorkere Compensation Insurance or a certified copythereof(Sec. RECEIPT#
GAS EA.SYSTEM-11NC.40UTLErSPARK FEE' Y N '
3800,lois C.7
Policy . GAS 2k.SYSTCM-OVER 4(EAI RFCEEs'r# '
Com envJsQ - BUILDING DIVISION FEES
Certified copy is herebytuMe city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy E filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' _ GREASE TRAP ]TALO .
COMPENSATION INSURANCE - '
(rhbsectlonneed not becompletedlfthe penNt lsforonehundred dollars SEWER-SANITARY-'STORM EA'200FC' I Date Recei t#
($100)or less.) - WATER HEATER W/VENT/ELECTR 'ENERGYFEE Y_ N_
I certify that In the performance of thework fdrwhicle this pgonit is issued, Q�
I shall not employ any person In any manner s°as to become subject to the WATER SYSTEvI/TREATING
Worker Compensation Awe of rAlifomia. Date - PAID
ZZ Applicant NEW RES[DEIV'IIAL PIMB. SQ}T. Date Remi t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
F should become subject to the Workeri Compensation provisions of the Labor TOTAL:
47 Code,you moat forthwith comply with such provisions orthis permit shall be
Wj deemed revoked. BUILDING FEE
tL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a censtru@lon iendingagency for the perfomr ELECTRIC FEE
M Z ante of the workfor which this permit isIssued(Sec.3097,Cie.C.) - TOTAL:
() O - Lenders No. PLUMBING FEE 1 00
LL f L.ender.Addre.s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
..0 Icadltythatlhavereadthbapphatlonand statethattheabovelnformatlor, - ^
IL
U collusion,isrrect.I agreeto complywith all cityand county collusna and state laws PERMIT ISSUANCE FEES PAID:
} relating to building mmtmction,and hereby authorize representatives of this
H W city to enter upon the above-n¢ntiuned property for Inspection purposes( ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an it keep harmless the City of Cupertino - Date- - Recei I#
V against Ba601Mes,udgments,costs and expenses which may In anyway accrue - AIR HANDLING UNIT(TO 10,D00CFM) SUBTOTAL:
ago Inst dCity comequence of the granting of this permit. -
p AIR[-IANDLINC UNIT roVER t0,000CFM) CONSTRUCTION TAX
^�—�/
Signature of Applicant/ enactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture Wilding occupantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
reaterialaadefinedbythe Cu ertlno MunI I I Code,Chapter 9.12,and the
Health and Safety C c n2S32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
E] Yen
_ o .
Will the applicant future building occupant use equipment or devices VENIILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
silty Management Dist 7 - BOILER-COMP(ITT OR 100,000 BTU)
Yu o
ave read theh pus materials requiremenh under Chapter 6.95 of BOILER-COMP(OVIIt l00,Of0 BN) M Q 00
the Cali(omla Healt SafetyCode,Sections 25505,25533 and 25534.I JAN 9r e' �a s7� '1
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. '' SQ.Fr.
responsibility to notify the occupant of the requirements which must be met
prlort Issuance aCertificateof Occupancy, ex{Auraert•r��
�r or author an/-�.. !'r79]�OiL�
O Wnad agc6f Date TOTAL: ISSUED BY:
OFFICE COPY