20218APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pre'«t Identification
Building Addmsa: q
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PERMITNO.
20218
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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Comm raName: Lic.N.:
_
S t3
BUILDINGELECTRICALML GING-MECHAMCAL
CATFSARY
CONTROL
Architect/Engineer'. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
�'�(a(.
Add..,/,?L).:? �'/ 3 7�
❑ El ❑
PERMITISSUANCE
LICENSEDCONTRACTO DECWRATION
I hereby affirm that l am licntsd under provisions of Chapler9(commee
APPLIANCES RESIDENIAL
JOB DESCRIVTION
PANES
IngwitSddtlon 7W)of(Msion3ofthd BuNnand ProfeslonsCode, and my
license I, l force and offect,
Llmme ClassLich
Data Contractor)
ARCHITECTS DECLARATION
I understand my plana shall be used as pubBe maa rda.
301-i 000AMPS
OVER IODO AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hembyafflrmthat I am exempt fromthe Contractor'sLicense Law fou the
TFMp MEERORPOLEINST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requlms a permit to cerstroct, alter, Improve, derrolbh,or repair
any sousturc prior to Its bsaance,also requiresthe applicant for such permit to
file a signed statement that he is licensed pursuant to the provIsiom of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Conlrador's License Law (Chapter 9(commencing with Section 7000) of Divi-
sion 3 ofthe Busloessand PromadoesCode) orthat he is; ex¢mpstherefromand
VALUATION
the basis for the alleged exemption. Any violation of Stolon 70315 by say
applicant for a permit subjects the applicant to a civil penalty a net morethan
OUILETSSWITCIi(SEXTORES
five hundred dollan(SM.
0 1, as owner of the property, or my employees with wages as their sok
pensatioq will do the work and the structure Is not intended or offered for
NEWRESIDENTIALELECTR SQ.FT.
STORIES TITS CONSTRUCTION
sale (Sce. 7044, Business and Pmfemions Code: The Contractors License Law
docs not apply to an owner of property who builds or improves thereon, and
who doessuch work h(mselforthrough his own employees, provided that such
OCC.GROUP RFS. UNITS
improvement are not Intended or offered for eek. If, however, the building or
TOTAL:
improvement esold within one yeatrofcompinion, the owner-bullderwill have
t4Cjnurden of proving thathe did net bund or improve for purpose of sale.).
LJ L as owner of the property, am exclusively =trading with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
PERMITIRSUANCE
142,00
The Contractor's License Law does net apply to an owner of property who
Wild. or Improves thereon, and who contracts for such p5ojees with a
gIlt�ador(s)Bcenxd pursuan(to the Contrador'e Llcenm Law.
c LJ I am exempt under Sec. B 4 P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certNcate of consent m self -Imre, ora
certificate ofWorkers'Compewuon Insurance or a certified copy thenrof(Sec.
3800, lab C.)
FIXNRF_S PER TRAP
SCHOOLTAX Y_ N—
RECEIPT N
GAS E.A.SYSTEM-1 INC.a OUTLETS
PARK FEE Y N —
RECEIPT N
Policy N
Com any
GAS EA. SYSTEM-OVER4(EA)
BUILDING DI VIS ION FE ES
❑pdrtl(led copy is hereby to melted.
C
F1 Certified mpy Is filed with the city inspection division.
GREASE/INDUSIRL WASTE IMFRCFPIOR
PLANCI-IECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SAMTARY-STORMEA.200FT.
COMPENSATION INSURANCE
This sedton need n t W completed if the permit b for one hundred dollars
($100)or ldssJWATEN
1 armlythal in the performance of the work for which this permit is Issued,
Date Receipt#
HEATER W/VENT/ELECTR pO
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
1 shall not employ any person In any manner so as to become subject to the
Workers' Compensation Laws of California Date
Applicant
PAID
Date Remi t#
I NEW RESIDENTIAL PLMB. SQ.FT.
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you
should become subject to the Workera'Compereation provisios, of the Labor
TOTAL:
BUILDING FEE
Code, you most forthwith comply with such provisions; orthia permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL: 0^1�0
a W
ELECTRIC FEE.
Ihercby affirm perform
orkfo whin t i acomirudlon ld(Sec. 097, cy Cls.
Lendof erthe work for which this permitIsbored (Sec. 31197, Clv. C.)
lender'sNLme
Ianders Addreaa
PLUMBING FEE
s 00
QTY. MECHANICAL PERMIT TEE
MECHANICAL FEE
I certify that I have read this application and state that the above Information
lacorrect. I agree to comply with all city and county ordinances and state laws
PERMIT ISSUANCE
FEES PAID:
At= OR ADD 7O MECH.
refining to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for bupection purposes.
Mr) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, Pdg.ets, mets and expenses which may In any wayaccrue
Date Receipt#
AIR HANDLING UNIT TO 10," CIM)
SUBTOTAL:
LI
AIR HANDNG UNIT (OVER tO,ODOCFMI
CONSTRUCTION TAX
against said City in consequence of the granting of this permit'
Signatu m of Applicant/Contndor Date
IXHAl1S'r How (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppilcant orfuture building occupant store or handle hazardous
HEATING UNIT (TO 100,ODO BTU)
Date ReceI t#
rwterlal as defined by the Cupertino Mu nlcipal Cde, Chapter 9.1 2, and the
I ealth and Safety Cdd Section 25532(a)?
❑ Yes n No
Wllltheappllcant orfuture building occupant use equipment or devices
which emit hazardous air coma minants as defined by the Bay Area Air
Quality Management District?
Yes No
have read the hsza ous materials requirement under Chapter 6.95 of
HEATING UNIT (OVER 100,000 BTU)
pL;IV,00
VENTILATION FAN (SINGLE RESID)
ISSUAN
sj U/ 7
1 { 7t.yc J
IJ
/s
•a%
BOILER.COMP(3117 OR 100,0(10 BTU)
BOILER-COMP(OVEd 100,000 BTU)
the Californk Health & Safety Code, S oiom 25505, 25533 and 255M. I
understand that if the building does not currently base a tenant, that it my
napomibllity to notify the occupant of the requirements which most be rrce
" Qf ^VITA
NEW RESIDENTIAL MECH. SQ.FI'
prior to Issuance,Certincate of Occupancy.
A4:
ISSUED BY: ��.1'�i��OY L �L x� v"'
Owner or authorized agent 61Date
TOTAL:
OFFICE COPY