20492 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMITNO.
Building Add.. tnwc.J,_q 20492
wirer_AA. ante:' t Le-tilCITY OF CUPERTINO-BUILDINGDIVISION _ !_Q0
con tnr.Name: ` APPLICATION /PERMIT l
BUILDING-ELBCTWCAL PLUMBING-MECIIAMCAL CATEGORY CONTROL j b
Arc /Engineer. Lle No: (/.)
L'- CIBUILDING PERMIT INFO
\J QTY ELECTRIC PERMIT FEE�y�
Address:21 - PERMITISSUANCE ��� i�
LICENSEDCONTR ROR'S RATION
I hereby affirm that l amlke under prwls,oa of Chapter9(comment- APPLIANCES-RESIDENTIAL JOB DESCAB'TfON
Ingwith Section 9000)of Dlvlsion3ofthe Busiaxand ProfnslonsCode,and my
licLI nsebtorte and effect. PANELS �IT\ �� VtIt� 4,0License ChaIasa LIC.. `I
Date Contractor UP TO 2DOAhvs
ARCHITECPS DECLARATION W
MZ Iundcntand rtry plan shall be used as public records OVEROVERIW0AMOAMIS SQ.FT.FLOOR AREA 4/SQ.FT.
O
Lltrnxd Professional SIGNS ELECTRICAL
<cW.. OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MLSC
Thereby a(Orm that lam exempt from the Contractor's License loafer the
following reason.(Sc tion]Qi15,Business and Pm(csslons Code:Any Aty or
TLMP.METEZ OAI'OI.E INST.
�ppcounty which reclaims apermit to moat,alter,Improve,dertnlbh,or repair
P 5.'aa any structure Infer to its taws me,also requires the a pplicant for such permit to POWER DEVICES
((F>d1 V file a signed statement that he is licensed pursuant to the provislom of the
}pp}S5,,Ow Contractor's Liceae Law(Chapter9(commencingwlth Section 7(k)l of Dot- VALUATION
F,�OQ s1on3o(the Business and Prolcss,oa Code)orthat hebexempt thercfromand SWIMMING POOL ELECTRIC
Q O the basis
for the alleged exemption. Any Wolatbn of Section 7Qit5 by any OUTLETSSWITCHESEXTURES �dc D A /) d.4
ppilcant(ora permitaubjeta the appllcanuoa dull pealty of na morethan
dre dollam($500), NEW D EATI
�pyy .owner of the pmperty,or my employees with wages as their sole STOWFS TYPE CONSTItUCT10N
�Z vmpensation,will d o the work and the stachare Is not Intended or offered for
Ole(sec.9016,Buttress and Pmfexiom Code:The Contractors License Law
�SS docs not apply to an owner of property who builds or improvesthereo^,and OCC.GROUP AFS.UNITS
P. whoclonsmuchwrokhimselforthrough hisownemplgees,providedthatsuch saa
Improvements are not intended or offered for sale.If,however,the buildingor TOTAL: l
Improvement bold withinoneyearofcompleiontheowner-budderwlll have
try�+edenofproving that he did not build or improve for purpose of sale.). QTY. PL GP E FLOOD 7DNE APN
LJ L as owner of the property,am exclusively conloutleg with ikvnxd p ISSUANC '1
contratonto corLwnse Law does
net
apply to an t and Profession Code:
The
Contractor's License Taw don na apply to an owner d propeoy who .DRAIN&VFM-
wilds or improves thereon,and who contracts for such projects with a (EA)
➢t(ad^r(s)Licensed pursuant to the Contractors License Law.
<qFEE SUMMARY
LJ I am exempt under Sec B& P C for that reason W PROTECT.DEVICE
Owner Date f DRAIN OOF,AREA,COND. �t C' SANITARY Y N_
RECEIPT M
WORKMAN COMPENSATION DECLARATION FTX I'ER �7y Sp{ODL TAX Y N
❑1 hereby a(flnn that I have a certlRote of consent to self-insure,ora C.V RECEIPT M
ceni(Icate o(Worken'Compavatlonlaurance ora certi(led copythemo((Sec. ( GAS EA.SYSTEM-1 IN Ef5 (Z PARK FEE Y_ N
3800,Lab C.) a AFDE�T a
Policy N GAS.EA.SYSTEM-0VER 6(FiA)
Com any BUI LDING DIVISI ON FE IS
❑pcetified copy V hereby fumiahed. GREASE/INDUSRtL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city leepredmn division. /
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
.
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT
(This section need not be completed If the permit Is for one hundred dollarsDale Recei t#
(SIM)orlose.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I trolly that in the performance of the work for which this permit Is Lowed,
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Worken'Compensation laws of Cali/orris. Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.I•T. Dale Recei t#
Z O NOTICETO APPLICANT.to
.hen Workers'
this at ion Certificate of Exemption,you
H W shouldbecome
most
eubFtmlhe comply
Compeamlonprovhloarmit the shall
TOTAL:
Cndnedrvoked.forthwith comply with such provlsloa orchis perhtshallhe BUILDING t
W 9 deemdrevoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE O
CL Ihembyaffirm that them is a construction lending agency for the perform ��.r� ELECTRIC FEE
M Z ance ofthe workforwhichthls permit It Issued(Sec.3099,Clv.C.) TOTAL: 6100
rs Name PLUMBING PBE
00 Lende
LL 1— Iender.Addree, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythat l have read this appllcationand statethatthe above Information
1 bmrret.I agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE (eZCD FEES PAID:
relating to building construction,and hereby authorfre representatives of this a�.rxsaSA
F N city to enter upon the abmvo-merrioned property for inspection purposes. ALTER OR ADD TO MECH. W
Z Date Receipt#
(WeJ agree tm save,indemnity se t keep harhich the in
of Cupertino
V .gains,said mrd meat pe swhich rtuyin any waya<trme AIR HANDLING UNIT
(OVERWOCFM) SUBTOTAL:
against sola Qf Inc n ^R of mit R^^it. f p1R HANDWNG UNff(OVER IO,000CFM) CONSTRUCTION TAX
SI hareof Applicant/Contrator Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATE ALS DISCLOSURE
Will the.pplicant or future building otup.m store or handle h.rdous HEATING UNIT(TO 100,000 BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
HrAthand Safety Code SMlre 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: s ,
❑ Yea in No
Will lheappllcant orfuture building mccv p.et.,c equipment or devices VENTILATION FAN(SINGLE RESID) ISSU DATE
which eht harardous air cents entrants as defined by the Bay Area Air
Quality Marugemcnt District? BOILER-COMP(3HP OR IDOOW BTU)
Yes INo l r
Ihave read the h..rri us materials requirementsuruder Cha pier 6.95of BOMER-COMP(OVER 100,000BTU) 3 (�
Ile California Health&Safety Code,Sections 25505,25533 and 25536. I 1 yo
�✓ understand that if the building does not currently have a tenant,that It le my NEW RESIDENTIAL MECH. S'Q.FT.
responsibility to notify the occupant of the requirements which must be met Of P,' .
Ori to Issuance ofaCertificate o(Occupancy. /
Owner or authorimd agent DateTOTAL: ISSUED BY ` L
C CX/
OFFICE COPY