20968 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PF:RMITNO.
Building Address: - 20968
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- G G �9�M7 l8
nen• ams: one: A
wSiz-f fh ash`- CITY OF CUPERTINO,BUILDING DIVISION
cono-aanraName: n Lk. °: APPLICATION /PERMIT
BUfLDINGELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROLp
Ar]amet/Engineer. Lie.No:
Jr�Ne i0oc J. c Qct ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address.: S PFRMITISSUANCE
LICENSED CONTRACTOR'S
pr DECLARATION a
I hereby
oflrmlhatlam Bcm3ofthe erpemand of Chapter9 ,.rsne APPWANCESRESIDENITAL JOB DESCRII'fION
Ing with Section 7000)of Division 3 oflhe Businem and Profeu(onsCnde,and my
Ilcense is In fy1l toay�,rfJ��t PANELSUP TO 2DOAM
Lkenu CIasF"_a/ C E1L N_� 1/ 5
Data .}"�-qi_Contnnor �+QR F-.•/n-R�l. eoc
ARCHITECTS DECLARATION 201-1000 AMPS
re O I understand my plans shall be used n public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
¢ ° OWNER-BUILDER DECLARATION SPECIAL CBtCU1T/MISC
71.,�a IhercbyafOrm thatI am exempt from the Contractors License Law for the
op following reason.(Section 7MIS,Business and Professions Code:Any city or
OZFpppp"t9+ county which mquirwa permit haeoniatruct,alter,Improve,dennlbh,or repair 7RMP.METEROR POLE INST.
K�Y ; anysuunure prlort°its Issuance,also requireelheapplicant for such permit to
�C c. file a signed statement that he b licensed pursuant to the provisions of the ]OWER DEVICES
Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi-
"'30�' slon3 ofthe Sustnessand ProfenloroCode)orNat he b exem thercfromand SWIMMING]VOL ELECTRIC ALUATION
a'`y Sn_g the bests for the alleged exemption. Any violation of Section 7031.5 by an
applicant for a pemet mm
bjece,the applicant to a civil penalty d not ore than OUTLETSSWITCFIFSFlXTIIRFS
o. five hundred dollars($500). NEW RESIDENTIAL ELFGTR SQ.Ff.
J 6 ❑1,as owner of the property,or my employees with wages as their sok TYPE CONSTRUCTION
pensation,wW Bothe work and thestmeture b not intended or offered for
5 ❑ sale(Sec.7044,Business and Professions Code:The Conlranoes License Law
does not apply to an owner of property who Wilds or improves thereon,and C.GROUP RFS.UNITS
who does such work himself or though his own employees,provided that such
Improvements arc ns.Intended or offered for sale.If,however,the building or TOTAL:
Improvement bsold within one yea rofcomplation,the owner-builderwill have
t rd an of proving that he did not build or improve for purpose of sale.). QTY,Lj PLUMBING PERMIT FEE
e FLOOD ZONE AVN
corL as owner tr the property,am exclusively contractingrowith licensed PERMIT ISSUANCE
The Contractor'.
to roretron the project(Sec.apply
to nev and of property
Code:
The s or improved
ed the Law docs net apply to an owner of propesy who ALTER-DRAIN k VENT-WATER(EA)
Wilda or Improves thereon,and who t contracts for such plojens with a FEE SUMMARY
ro,bt(�ctor exempt
under Secnt.
the Contraetorb License PLaw. BACK FLOW PROTECT.DEVICE
1_J 1 am exempt under&c. B &P C for this rescan
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
Owner Date RFCEfPf X
WORKMAN COMP FSi5AT10N DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have o certificate of consent to op thereof
ora RECESPF X
MM,UbofWorkeri Competsatlonlwuranceoracenlfied copy Chemo((Sec. GAS EA.SYSTEM.1 WC.4OUlI.ETS PARK FEE Y N
3800.Lab C. a .s RECFRTX
Policyp— L9lL', 9O y(rV y 3/J GAS EA.SYSTEM-OVER 4(EA)
Com any B UILDING DI VI SION FEES
Lj Certified copp is hereby tum
�ertified copy b filed with theecity
inspection division.
ciGREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE:OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FI. Date Recei t#
(Thissection need not be completed Lithe permit b fm one hundred dollars
WATER HEATER W/VENT/F7.FCTR ENERGY FEE Y N
I cemlythat in the performance of the work for which this permit is Issued,
1 shall not employ any person In any manner an as to become subject to the WATERSYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Dale Recei t#
Z O NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you
should become subject to the Waders'Compensation provisions of the Labor TOTAL:
K w Code,you must forthwith comply with such provision or this permB shall be BUIL12ING
FEE
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirmthat there Is a construction lending agency for the perform TOTAL:
U ELECTRIC FEE
M Z arm afthe work!orwhkh this permit b noted(Sec.3097,CIv.C)
O Lenders Name PLUMBING FEE
F- Lenders Addmss QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W Icect.Iaatlhevc mad comply
with all
state that theordina above Information
4 brorrM.Iagrceto comply with all tltyand rountyordinanmand state laws / 1'FRMRISSUANCE / FEES PAID:
} N relating to building construction,and herebyauthorizercprcsentativesofthb -
city toenter upon the above-mentloned property for Wpenton purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
U against Babilities,judgments,costs a nd a uses m
whtchmay(°anywayaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again Clly`n cons nce o(the ting of this permit.
p\ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sg. !Applicant/Contractor Dat - 1 EXHAU511001)(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,(100 BTU) Date Reoei l#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the IF
I alth and Safety CrdeSection 25532(s)I HEATING UNIT(OVER 101IM BTU)) TOTAL:
❑
Yes 2R
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdous air roots minants as defined by the Bay Area Air P-410
ri Qu a Illy Management [gN- BO LER COMP OF PGR 100,000 BTU) emit PPS►
Y. ��IJJ - �/
have read the
Health
a afetmaa Code,materialsSe tions 2menbundmndChapter 2S54. I of BOILER-COMP(OVER IW,000 BTU) MA
the understand
California Hmlth l Safety Code,Sections 25505,have
a tenant,and 255]4. I
understand thtonctil the occdmsnotarrcnlly haveahosad Rbmy NEW RESIDENTIAL MECH. S'Q.IT.
prior
responsi to of.clhe ocevpant of the immentswhich nuns(be met
prior( ceo(a Cenlficat o Its /jpsa CI as.-_ __
Y1 OQ
n a horized agent Date ISSl/ED BY:] /
TOTAL:
OFFICE COPY