26722APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
C ITY OF CUPERTINOBUILDING - ELECT RICAL PERMITNO.
BUILDING u1vlsloN APPLICATION/PERMIT PLUMBING - MECHANICAL � � f !Q d]
L
M BUILDING PROJECT IDENTIFICATION _. ( G
20771 McClellan Rd.
LICENSED CONTRACTORS DECLARATION
zZ Ihmelw anon than l am licensed under pmvisinnxof Chapter9(commencing with
00 Section 70061 of Division 3 of the Business and Professions Cade. and my license is in
WE full force and effect.
U w License ClassG 4 3 ic. ag 4 6 q 6 1
<y Data Common,
0Z
ARCHITECTS DECEkzsjtgiplQLL , I'' ll I n a C f
O1 undersand my plans shall be used as public records.
=u
Ej Licensed Professional
aVzQ OWNER-BUILDERthe
I hereby affirm tort 1 am a+emit form. the e CCaonvenor's License law co the
0. following )arson. (Season 703L5, Business andProfessions
ve de m demolish.
Code: Any city m county
which i. issu a c. alsl ro ennswn, alter, improve, demolish, fi repair any smunme
>.:F p of he 1, licensed puow nn to h the Provisions
f,h aUConton, It . Lic a se La nat[m[nt
p Ionheislicensedpursuantmthe) of Distorr,f the Convenor. License Law (Cherie)
=m zz or(that eels ingwith Sdocrafrom0W)of Division 3ofde Bde. trial exemption. Myvr,rm Cod e)
Sectio 7031. by nyappssm an for a Perist subjeas$aapplMyviolationpenity of
ZQ Section 703 by anyapplicantforapermit subjects Ne applicarltmacivil penalty of
20 not marc than Oveffiepm dollars yemp. -
_� ❑ Lesowrk. and
withwagwasalei(See 044,Bsiness
3m will dotocwons and Mc oComricture isnot immense offered Law
out (Sec. t0 a4, Business
of
and Profusions Cade: Thr improves
the tan. Lienee Lew docs nal apply tom owner of
own employees
whobuilds or imph at such
unproved whodoes such work h roffendthough his
employees, provided Nn such improvements an, not intended m offend for safe. If.
however. the building or improvement is sold within one year of completion, do,
will have @e Darden of proving That he did not build or improve far purpose of
alt.).
❑ Las o a pmjccepropmY�em Business
and Profesng sions
Cth lic:) sed The oner m
Drano the project (Sec. 70x4, Business entl Rohobuil Code:) The Convacmrs
License Lawdocs nal apply ctmownerofproperty lihose Idsofimproves Nercmn, and
whocontractsLa is for such projects with aconvumr(s)1icenxd pursuant to the Contmnor's
License Law.
❑ I em exempt under Su. , B @ P C fm Ibis reason
WORKMAN COMPENSATION DECLARATION
❑ Ihembyaffirmthmihaveamnifimwofconxnttoself-insum,oraamBwn:of
WorkersCompenvtion loommna or a certified copy thereof (Sce. 3800. Lab C.) which
covers all employee x under this parrot. ^' S 2 0 2 5 0 1
Policy # 9 A
Company
❑ Cenifiedco y i ed. '
CX Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
phis section need not be completed if Ne permit is formic hundred dollars (SIM)
mr less.)
I certify but in the performance of the work for which this remit is owed.I shill
nm employ tiny person in any manner so as to become subject to the Workers
Z Compeasadonlnwsof Cnlifomin. Data
—
z
NOTICE TO APPLICANT: IL won making this Ceni ficam of Exemption. you should
fA become subject o the Worker s Compensation provisions of the Labor Code, you must
fonhwim comply with such provisions or this permit shall be doomed invoked.
Q CONSTRUCTION LENDING AGENCY
Z I hercbv affirm Nat there is a construction )ending agency for the performance of
O
the work for which this Permit is issued (See. 309]. Civ. C.)
Lender's Name
Lander s Address
U I anify that I have read this application and state that he above information is
4 toren, loge.. to comply with dl city and county ordinances and nam laws mating to
building construction. and hereby authorize mpres natives of this city to enter upon the
a1nova-me i'mied property for inspection pm,mmi.
(W gree to save, indemnify snit keep harmless the City of Cupertino against
'abilities, ud cros.cssstsande es whichmaymar,way [Lw`" eagaiessaid City
i granting Aix it. 11m
N 1
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmsrdous mamrial
as defined by the Convertor, Municipal Code Chapter 9.12, and the Hcallh and Safety
Code, Section 25532(a)?
Cl Yea ❑ No
Will the applicant or future building occupant use•,tipment or&vices which emit
11bnvmdo., no conmmina ds as defused by the Bay Amo Air Quality Munagemrmt
IDinrict?
❑ Yo ❑ No
I have read the hurardous muterialn rectincmcros under Chapter 6.95 of the
California Health & Safety Cade. Sections 35505.25533 and :5534. I undersand that
if the building docs not currently have a anent, that it is my mspansibility in notify the
occupant of the re9u&ementa which must be met prim to issuance of a Cmilicam of
Occupancy.
Owner of mthmimd agent Doc
0
- — -
PERMIT ISSUANCE
BLDG
El
ELECT PLUMB M
❑ ❑
APPLIANCES - RESIDENTIAL
TEMP. METER OR POLE INST.
J'ORRDDFSCRipTiON
PANELS
J
SWIMMING POOL ELE
ur ro z1ro AMPS
h Y
\i
OUTLETS - SWITCHES-XTU ES.
301-1000 AMPS
SIGNS ELECTRICAL
BUILDING FEE
nI
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
r r.", PI7
J
SWIMMING POOL ELE
IC - -
h Y
\i
OUTLETS - SWITCHES-XTU ES.
NEW RESIDENTIAL ELE
_10 ET.
DRAINS- FLOOR. ROOF, AREA, GOND.
IDSI:#M
PERMIT ISSUANCE
BUILDING FEE
ALTER - DRAIN &VENT- WATER (EA)OUTSIDE
TOTAL-:
ELECTRIC FEE
BACK FLOW PROTECr. DEVICE
^,i "Lr' ti,-, r---si
MECHANICAL'PERMIV. :1f�.,.a,.a,s IFEE�:j'•
^
PLUMBING FEE
FEES
SANITARY
YN
RECEIPT#
DRAINS- FLOOR. ROOF, AREA, GOND.
SCHOOL TAX
Y N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE
YN
RECEIPT #
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
EXHAUST HOOD(WIDUC)
GREASEWDUSTRL WASTE INTERCEPTOR
GRADING FEE
HEATING UNIT (TO IM." BTU)
GREASE TRAP
SOILS FEE
HEATING UNIT (OVER 100.000 BTU)
SEWER - SANITARY - STORM EA. 2WFT,
ENERGY TEE
WATER HEATER WIVENT/ELECIR
PAID
Data
Receipt#
WATER SYSTEMP EATING
NEW RESIDENTIAL. PLMIL SQ. FT.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL-:
ELECTRIC FEE
^,i "Lr' ti,-, r---si
MECHANICAL'PERMIV. :1f�.,.a,.a,s IFEE�:j'•
^
PLUMBING FEE
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT OVER 10,000 CFM)
EXHAUST HOOD(WIDUC)
PAID
Doc
Reccipt#
HEATING UNIT (TO IM." BTU)
TOTAL:
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (310 OR 100.000 BTU)
BOILER-COMP(OVER IW,00)BTU)
ISSUANCE
'-
I E
Ei
AUG
ISSUED IM
_DA
E 8 1994'
NEW RESIDENTIAL MECH. SQ. FT.
LL: