20713APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Address:
1
2 0 713
canerSS• a;,r . one.
R�1S
CITY OF CUPERTTN0.8UILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECnUCAGPLIIMBING-MMIH LAICAL
A A
7-(v �D
emo-ada.•s name: t (1% Lnk.�Nye:
�t'4' !soyC-Wc_ 4l[An
CATEGORY
CONTROL
Archhect/Engineer. Lk. No:
�
o�
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add. I jb -
❑ ❑ ❑
I PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihembyafflrm that l am licensed under provisions of Chapter 9(e,mmme-
Ingwlth m 11 fi000)of Dl effect ofthe Businesaand Pro(esslonaCode, and my
license b In fu�0 ff�o���reaapp��nd dim.
License CbXN!X1LIOM 440kga J
APPLIANCFSRESIDENTIAL
JOB DESCRE'1'ION
PANELS
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public record&
l
701-1000 AMPS
OVER1000AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCU1T/M19C
OWNER -BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's Licenselaw for the
TEMP. METER OR POLE INST.
�^I
ppkyER DEVICES DU
following mases. ISe Hon703L5, Buslneaand Prefnasions Code: Anydtyor
cmntywhichrequbesapert ttommtmct,alter,Impmve,de=lbh,ormpalr
anystNetum prlorto Its lssance, alas, requireathe applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9(mmncencing with Section 7000)of Divi-
sion3 ofthe Busu essand ProfessiomaCode)orthat he is exempt therefmmand
VALUATION
the bsais far the alleged exempian. Any vlolatlan of Seddon 7a11S by any
applicant fora permit subjects the applicant to a civil penalty of not more than
OUTLETSSWITCHFSFIXTURES
NEW RESIDENTIAL ELFCTR SQ.Ff.
five hundred dollars ($500).
F-1 1, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, wdI do the work and the structure is net intended or offered for
sale (Sec. 704A Business and Professions Code: The Contractors License Law
doe,notapplyt.anowner of property who builds or improve, therms,and
whodoe,suchworkhlmself orthraugh Msownemplayee,, provided that such
.GROUP
RIS.URJITS
improvements are not Intended oroffered for sale. If, however,lhe building or
TO
Improvement baoidwithlnoneyearofcomplMWn,theowner. uilderwRl have
th,�nrden of proving that he did not build or improve or purpose ofsaleJ.
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Sec. 7004, Business and Prefe dims Code:
QTY. PLUMBING PERMIT E
FLOOD MINE
APN
PERMIT ISSUANCE
The Contractor's License Raw does sat apply to an owner of property who
Bds or Improves thereon, and who contracts for such p(ojects with a
pursuant to the Contractor's License Law,
W➢Ifador(,) licensed on
111 am exempt under Sec. B h P C for this reasonIIS
ALTER -DRAIN &VENT- WATER (EA)bu
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND. If
ANITARY Y N_
REC= #
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that 1 have a certificate of consent to se161nwre, ora
certificate of Workers Compensation Insurance ora certified copy thereof(Sec.
3800, Lab C.)
}T%"lVRFS PER TRAP
SCHOOLTAX Y_ N_
RECEIPT 0
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FFP Y N
RECEPT M
Policy p
�A
GAS LA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION RTES
rOned copy 6 hereby filed the ed.
rtRIed copy V filed with the city Inspection division.
GREASE/WDUMRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF E%EM PFION FROM WORK ERS'
PAID
SEWER-SAMTARY-STORM FA. 2(IOFT.
COMPENSATION INSURANCE
(This section need not be completed lithe permit le for One hundred dollars
Date Reed t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
(5100)or less.)
I mrtlfy that In the performance of the work forwhich this permit is Issued,
WATER SYSTEM/TRFATING
I shall not employ any person In any manner m as to become subject to the
Workers Compensation laws of Cafifomia. Date
PAID
NEW RESIDENTIAL PCMB. SAFE.
Applicant
Date Re eI t#
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you
amid become subject to the Workems' Comperaation provisions of the Labor
TOTAL:
BUILDING ' EE
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
I hereby afirmthat there camrotmdion lendtngagency forthe perfomt
Ince of the work for which this permit Is issued (Sec. 3097, C(V.C.)
Lenders Nature
Lender&Add..
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
1 mnlfythat i have read thisapplicationand state that theabove information
ismrrcd. Iagreeto mmplywith a8 city and county ordinances and sate laws
PERMIT ISSUANCEFEES
PAID:
relating to building construction, and hereby authorize representatives of this
city to enter u Pon the abavcmentlored propertyor inspection purposes.
(We) agree to save, Ind.comfy and P Fe Cltyy,)wy. of rtlno
against liabilities, pd menta, costsand kh yin any
Date Receipt#
ALTFRORADDTOMECH.
MR HANDLING UNIT(TO 10,0DO CFM)
SUBTOTAL:
agmmt sold Cdyi sryu o e I ofth emmnit a
/a
AERHANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
51 N p n /Comncmr a
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CFO 100," BTU)
-
Date Receipt#
Illi pplimat or future building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I lealth and Safety Code Section 25532(a)T
❑ Yes M No
Will the applicacat orfrture building occupant use equ ipment or devices
HEATING UNIT (OVER IW OM BTU)
TOTAL:
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area AG
IQuality Management District?
,Quality
Yca � No
havcread the hazar oua naterialereq.irementsunderChapter6.95 of
the California health k Safety Code, Sections 25505,25533 and 25534. 1
understand that lithe building does not currently have a tenant, that it k my
pA`
a
1' { i u iyyU
T s '
BOILER -COMP DHP OR 100,0(0 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
priorto issuance ofa Certlfkac ofOavpancy.
Cityof YIoertinW
ISSUED BY:�
Owner or aulhmired agent Date
TOTAL:
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OFFICE COPY