19794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProMct ldentifWticn PERMIT NO.
Building Address: 19794
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nen came: phone: =AATE
ftZ IL( CITY OF CUPERTINO-BUILDING DIVISION .,..���,�QO
tractor's a LIc.No: APPLICATION I PERMIT 1
- / '� � z BUILDINGELECTRICA4kUMBING-MECHANICAL CATEGORY CONTROLp
Mtect/Engineer: SO wNo:
C CBUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: LICENSED CONTRACTOR'SDECLLA TION PERhBTI55UANCE 1:1 ❑ ' 1:1T hhereby affirm that l am Bcensed under provisions of Chapter 9(exammewc, APPLIANCES-RESIDENTIAL IOD DESCR,II��-lI-ONS_ (/•(
InenseiSection 7000)of Dloffect o(Ihe Bupneuand ProleulonaCode,and my fy�" - 1 - _license la in = defeat. PANELS "IWe�Va'WIaL/+
License Clam Contractor
6 -'
Date Contractor
ARCHITECT'S DECLARATIO 201-1000 AMPS
p�p�uu
W;. I understand my plane shall be used as public records. OVER IODO AMPS SQ.FT.FLODR AREA $/SQ.FT.
Licensed Professional - SIGNSELECTRICAL
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OWNER-BUILDER DECLARATION SpECIALCEiCUIT/MLSC
Zt, Iherebya(Rrm thatl amexempl fromthe Cortmetur'e License Lawfathe
q❑ following recon.(Section 90315,Budneu and[hofeulans Code:Any city or
Fcountywhich requires a pemNt to construct,alter,Improve,demolish orrepair TEMP.METER OR POLE INST.
'1� aoystructom prlractato Its Wuance,alsorequlrestheappllcant forsuch permit to POWER DEVICES
C file a signed statement that he b licensed pursuant to the provisiom of the ,
3µi.
Contractors License Law(Chapter 9(commencing with Stolon 7000)of Divi- SWIMMING 1- 0L ELECTRIC 1 4717
LUATION
OJ pon3o(the Business and Profesalons Code)orthat hela exempt therefromand
<] the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXIDRES r-'-'
O appliantfma permitsubjecte the applicant to a civil penalty of not..the. o
R five hundred dollars(5500).
❑I,as owner of the property, NEW RESIDENTIAL ELECTR SOFT RIES TYPE CONSTRICTION
p ork,a or my employm with wage r there wk
7< compensadon,willdothe workandlheetrucwrebnot Intended or offered for
O sale(Sec 7044,Bwineu and Professions Code:The Contractors Llama law
$ dare net apply to an owner of property who builds or Improves thereory and OCC.GROUT' RES.UNITS
who does suchwork himself orthrough his own employees,provided that such
- Improvements are not Intended oroffered for sale.If,however,thebullding or TOTAL: I
ImprovemenMeeold within oneyearofcompletlorytheowner-bullderwili have '
tlig.Ilurden of pmving that he did not build or Improve for purpose of ale.), Cry. PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to doestruct the project(Sec.7044,Business and Professiores Cade: PERMITLSSUANCE
The Canmectoes License Law does not apply to an owner of property who ALTII4ARAIN&VENT•WATER(EA)
beefids or improves thereon, and who embrace.for such p(ojMs with a FEE SUMMARY
cgalpador(s)Bursted pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
UI am exempt under Sec. B&P C for this reason
OUTSI DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN'COMPENSATION DECLARATION FIXTURE-PER TRAP SCHOOLTAX Y N_
F11 I hereby affirm,that I have a certificate of consent to self-Inaure,a a RECEIPT N
S
certl0cateofWorkere'Compensatlon lnsursnu on artifled copythereof(Sec. GAEA.SYSTEM-1 INCAOU-METSPARK FEE Y N_
RECEIPTIf
C.I1ryN GAS EA.SYSPEM-OVER4(FA) -
Cm an / BUILDING DI VISION FEES
oCDCertifiid copy b hercbyturnla CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certllied copy V filed with the city
city ty Inspection division. ,
CERTIFICATE OF EXL-MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIURM EA.200FT. Date RCC21 tJl
(This section need ma be completed if the permit Is forone hundred dollars
(81I(crrlesa.) - WATER HEATER W/VENT/ELECTR ENERGY.FEE Y N
I cert Ines.)t In the performance of[he oak for which this permit is laevM,
r I shall not employ any person In any manner so u to become subject to the
Worker WATIR SYSTEM/TREATING Compensation Laws of California. Date PAID
-
Applicant
Applicant Date Recei t#
Z Z NOTICE TO APPLICANT:If,after uWng this Certificate of Exemption,you NE'WRESIDENTIALPLMB. SQ.FT.
F O n
should beeore subject to the Worken'Comperwtlon provisions of the Labor TOTAL:
tl3 Cod,you most forthwith comply with such provisions or this permitahall be BUILDING
FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE L
d C Ihereby afRrenthat thea lea construction lendingagenry forthe perform TOTAL: ELECTRIC FEE
Z anceofthe workforw),lch this permit la issued(Sec.3097,CIv.C.)
V O Landers Name PLUMBING FEE
IL F Lender's Add., QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertilythatl have need thisappliationand starethattheabove information
W lamrrect.l agreeto complywith all city and county ordinances and pate lawn PERMIT ISSUANCE FEES PAID:
4 relating to building construction,and hereby authoram representatives ofthb
� city to enter upon the above-mentlumd property for inspection purposes. ALTER ORADDTO MFCH.
(We)agree to save,indemnify andkeep the City of Cuperfloo
Date Recei t#
."But liabilities,pdgments,"sand expenses whichmay In anywayaccrue AIRHANDLINGUNITUO10,000CFM) SUBTOTAL:
ei tsald City co en aafthegraming ofthlepermit
914PAIR HANDLING UNIT(OVER lB,mocFM) CONSTRUCTION TAX 41
'Ig turerf Applicant/Contractor Date, EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HA2A RDOUS MAMA SURE
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Recei t#
-dal as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the IRA
�
HEATING UNIT(OVER 100,000 BTU)
It and Safety Cad JNo 25532(a)7 TOTAL:
Yea No VENTILATION FAN RESID)
I the aiteard us air town,refusal.
asc part allrud by eclulperthe Bay Areart devices I 11 K 1 S NCE DATE
Iri'd
it havarscusairrict? arab as defined by the Bay Arca AU
mgemunt DiaWct7 BOR.FR-COMP OF1P OR 100,000 BTU7
�Noad the hue ua materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) GO riinp��n
la Health&Safety Code,Sections 25505,25533 and 25534.1
that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFIifty to nilly the ompant of the requirements which must be ret �cuanceofaCertlfkateo(Oaupanry.authodred agent - Date TOTAL: ISSUEDBY: s+o�
OFFICE COPY