20735APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Bio&a v+ PwAft OupwArtwO
PERMIT NO.
207 35
are.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTWCAL-PLUMBINGMECHANICAL
A.
Contranora Name: LI). Na:
N G a �/ S�BI�
CATEGORY
CONTROL y1
l9
AmhitM/Engineer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/�•Zs GuI �j9
Address: Iry %/� �W
El D 11
PERMITISSUANCE
LICE SIiDCONTRACTOR'SDECLARATION
I humby affirm that lam licensed under provisions of Chapter9(commenc.
inSection of Division 3 afthe Business and ProfessonaCods, and my
license 1, 1. fun force and effect.
License Clan Lk.#
Data Contractor
ARCHITECTS DECLARATION
I understand my plars shall be used as public records.
Licensed Professional
OWNtR-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 7031.5, Business and Professions Code: Any city Or
countywhichrryuimaper Wmmtmn,alter,impmve,demollah,orrepAr
any structure prior to its Issuance, also requires the applicant fee such permit to
file a signed statement that he b licensed pursuant to the provl+lom of the
Contractor's License Law Cbapter 9(commencing with Section 701 of Diel-
anon 3 of the Buelnma end Pro ose.ra Cesde) c rthat he is exempttherefmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjensthe applicant to a civil penalty ofnet more than
five hundred dollars (S500).
nI, as owner of the property, or my employees with wages as their sole
compensation, will dothe work and Ihestmtlum V not Intended or offered for
sale (Sec 7094, Beenecas and Professions Cade: The Contractors License law
don not apply to an owner of property who Willa or improves themoo.and
who doessuch work himself or through his own employees, provided that such
improvements arc not intended oroffered formic. If, however, thebullding or
improvement Issold wilhinoneyearofeompletion,the owner-builderwill have
thelzurden of proving that he did not build or Improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with Becr sed
contractors to [outrun the project (Sec. 7044, Business and Professions Code:
The Contractor'. Limns) law does not apply to an owner of property who
Wilda Or Improver thereon, and who contracts for such pkeJects with a
cq�t snorts) licensed pursuant t0 the Contractor's Limnee Law.
u I am exempt under Sec B k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DFSCRIxI ION
s_
- PANELS
UPT0200AM
701-1000 AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
S/SQ.FT.
ISIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
gyp. MEEK OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCH FIXTURES
VALUATION
4
NEWRESSIDENTIALELECTR SQ.FI'.
STOW
TYPE CONSTRUCTION
OCC.GROUIP
RIS. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
FLOOD LANE
APN
PERMIT ISSUANCE
ALTER -DRAIN It VENT-WATER(EA)
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECEIVE
Owner Date
WORKMAN COMPENSATIONDECIARATION
❑1 hereby affirm that I have a certificate of consent to re141n9ure, ora
certificate of Workers Compensation lrouranceora certified copy ther)of(Sec.
MOO, lab C.)
FIXTURES PER TRAP
SC[i00L TA% Y_ N_
RECEIPT M
GAS F.A.SYSTEM-1 INCAOUTLETS
PARK FEE Y N
BBC= N
Policy tl
GEm any
CAS G. SYSTI]N-0VER 4 (FA)
BUILDING DIVISION FEES
❑pCertWed copy b herebyfurnished.the
❑Certlf ed copy V filed with the airy inspection divi9lan.
CERTIFICATE OF EXEM PTION FROM WOR KERS'
COMPENSATION INSURANCE
(This section need net be completed if the permit Is for one hundred dollars
(fla metify that
I certify Nat In the performance of thewark (orwNch this permit Is lewad,
I shall not employ any person N any manner so as to become subject to the
Workers' Compensation laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers Compensation provisions of the Labor
Coda you must forthwith comply with such provlslons or this permit shall be
decreed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is amn9truction lending agency for the perform-
anti of the work for which this permit is Issued (Sec. 3097, Cle. C.)
Lenders Name
Lenders Address
atcryor manue,.ndstatela .
Iced. I utt agree
lhavetoc comply withall and state laws
Is correct. I agree to comply with all city and countyece representatives
or in onperp of Nis
propertymr Wileman purposes.
r upobuilding t comtsuntoq and hereby property
cityrelaing to enter
city tooeagee to the,inde-mentl an
(We) agree to save, Indemnify and keep harmless the City of Cupertino
against llabNties, judgments, costs and expenses which may in an wayamme
agains nsequ f the granting of thlc �.
CREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
1
PAID—�I�^ gaag
Date RCCCI t#
'S
GREASE TRAP
SEWER-STORM-S]ORM EA. 70017.
WATER HEATER W/VENT/W.ECTR
ENERGY PL•E Y_ N
PAID.
C R 1 t#
WATER SYS.IEM/TREATING
NEW RESIDENTIAL PLMB. SQFI.
/ TO AL:
BUILAG
FEE
SEISMIC FEE
_
TOTAL:
ELECTRIC FEE
PLUMBING FEE.
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FE
J Its—l7.
DaC Re IPt#
ALTCR ORADD TO MECIi.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBT AG
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Ig® reof Ap onlr nor
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulure building occupant store Or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I ealth and Safety CoQr<Sfction75537(a)I
❑ Yea '[�f ,ya
Will the applicant Or uturcbuilding occupant use equipment or devices
which emit bacardow air contaminants as defined by the Bay Arca Air
Quality Maw Element DI trill
Ycs
havereadthehaza us materials requ lmencrets under Chapter 6.95 of
the Cxlifomlallcalthh fety Code,Sectlone,25505,25533 and 75539. I
understand that if the building does not currently have a tenant my
responsibility to notify the occupant of the requirements wit must he t
prior rtiftca parry.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX D:
HEATINGUNIT(TO100,00011711J)
Data RCCCI tl
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
d
VENTI LATION FAN (SINGLE RESID)
ISSUANCE DATE
'+{{r ,
PAW
19g�
ISSUED BY: o1V
BOILER -COMP OFI'OR 100,000 BTU)
BOILER40MP(OVER 100,000 BN)
NEWRPSIDENTIALMECH. SQ.FT.
Fr or authorCeni agent a
TOTAL:
OFFICE COPY