20627APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Preect Identification
Building Address:
1 h� ✓ /
PERMIT NO,
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- 20627_
G
oGsate:
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S/'R^ItT Lt /alQ�T1yeLZ;L 7"77x1
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BOLDING ELFCTRICAI.PLUMBING-MECFANICAL
A
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Conimctm's Name: L(c. No:
CATEGORY
CONTROL k
ArcM1ltect/Engineer. Lie, No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ 1171 ❑ ❑
PERNITTISSUANCE a W
LICENSED CONTRm licensed under rDECLARATION
IMrebyaf0000 that l iA.10.3.fth..st.m.onsoffh..r9de,and
ingwlth in fun force ofd ficcn3o(the Buslneesand Proteaslom Code, and my
license is in Nll (orae and effect.
License Clam x. Conten -
Date G0111raLtOr
ARCHITECTS DECLARATION -
I understand my plass shall be used es public recons
Licensed Professional
OWNER -BOLDER DECLARATION$pp-C]ALCB2CUIT/
I hereby affirm m
that I amexempt frothe Conlream. License Law for the
followingreason.5todon70315, Busine.aand Professloru Code: Any dry or
countywhich requlrtre a permit to mm
rstci, alter, Improve, demo W h, or repair
a nystmmmprimtolts Wuame,aLwrequr kheappBcntfmsuchpermltto
file a signed statement that he to licensed pursuant to the provisions of the
Contractors License Law fCMpter9(commencing with Section 7000)of Ovl-
sbn 3 ofth.Buelnees end Profeasioru Code) orthat heir exempt themfmmand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects theappllcanl toa civil penalty of not more than
five hundred dollars (SM.
I, as owner of the property, or my employees with wages as their sole
mmpensadon, will do the work and the structure is not Intended or offered for
'vie (Ser. 7004, BR.ineas and Pmfenlms Code: The Contractors Lt.. law
does not apply to an owner of Property who builds or Improves t hereon' and
lfmth=ghhls wnempicyan,providedthalsuch
improvemenharenwt tendedorof(cmdfwule. ILhowever,thebulldingm
,oprovementbwldwilhinowyearofcompl&Wn'lh owner-bullderwillhave
ft.liurdenofproving that he did notbulldorlmproveforpurposeofsaleJ.
u 1, as owner of the property, am exc)usfvely contracting with licensed
contractors to cerstmct the project(Sec. 7041, Businenand Professe.. Code:
The Contractors License Lw don not apply to an owner of property who
bu0ds or Improves thereon' and who contracts fee such p(vjecta with a
rop¢ectm(s) Licensed pursuant to the Contractors License Law.
L� I am exempt under Sec B & P C Ion this reawn
AI'PLIANCESRESIDENI7AL
B
]OB DFSCRE''CfON
Q �'
'
PANELS
701 -IOW AMPS
OVER ROD AMPS
SQ. FT. FLOOR AREA
S/SQ, FT.
SIGNS ELECTRICAL
15C
gEMp,ME1TR OR E
ISDN'ER DEVICES
SWIMMING POOL ELEWRIC
r OUTLE IC J(Tl1R a S�
J
VALUATION
IOW R L
STORIES
TYPE CONSTRUCTION
�ya
TOTAL: 122 .ay
QTY, PLUM13NG PERMIT FEE
PERMIT ISSUANCE
p-
ALTER -DRAIN& -, ATER LEA)
OCC. GROUT'
RES UNITSwhodonsuchworkhim
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PR T. DEVICE
DRMNS-FLOOL,R P, AREA, COND.
pp(71TRpg PER TRAP
SANITARY Y -N
RECEIPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby afflrm that I have a certificate of consent to self-houre, or a
certBlcateo(Workeri ComInsurance aurance or a certified mpy thereof (Sec.
3800, Lab CJ
Policy If -
SCHOOL TAR Y_N_
RECEIPT M
GAS EA. SYST1M•1 INCA 0[TCLETS
-
PARK FEE Y .N
- RECEIPT M
GAS A) EA. SYS RM -OVER 4 (E
Com an-
Y
BUILDING DIVISION FEES
Certified copy is hercbyte city
Certified copy V (lied with the ccity Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This section need not be completed If the permit h fmone hundred dollars
($10(f) or less.)
I certlfythat in the performance of thework forwhlch this permit is issued,
I shall not employ any person In any nner w as to become subfea to the
WorkeriCompe t Laws ofGl n a/1_
Applicant �
NOTICE TO PLICAL :[,after ma ng this Ce trate of Exemption, you
should become subject to the Workers Compensation provisions of the Labor
Code, you must forthwith comply with such provblors orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there is construction nstruction lending agency for the perform-
ante of the work forwhlch this Permit b batted (Sec. 3097, Civ. C.)
Lender. Name
Lend.e.Address -
I certaythatl have readthisapphcalionand statethatlhe above Information
Vcorrect.I agree to comply with all city and countyordinancesand datelaws
Mating to building construction, and hereby authorfee representatives of thts
city to enter upon the above-mentlorsd property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu pert loo
against liabilities, judgments, .9 ... d expert. which Vmaayin any ways..
against sold Cify In onsequence aft grjm{Ip.atl this It.
L�`51/ 7�
31gnatureof AppLiant/Contractor Da
HAZARDOUS MATERIALS 'CLOSURE
Willtheapplicantorfuture building occupant store or handle havardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code SeY. ction 75532(x)7
Willtheapplicant Nobuilding occupant use equipment or device
which emit hanrdom a4 contambunts as defined by the Bay Arca A4
Quality Management District?
Yes ❑No
have readthehaurdousmaterialsrequlmmnHunderChapterb.95of
the California Health & Safety Code, Sections 75505,75533 and 75534. 1
andesta nd that if the building don not currently have a tenant, that It is my
responsib0lty, to notify the occupant of the requirements which most be mM
prior to Issuance of a Certificate of Occupancy.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recel t#
'
GREASE TRAP
BEWER-SANRARY-STORM F.A. 2kHrr
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N, —
-
PAID—
Date - Recei [#
WA.T.Q2 SYST M/TRPATIN'G
NEW R6SIDENI7ALPLMB. SQFT.
—7—
(TOTAL:
13UIL121NG
SEISMIC FEE
-- TOTAL:
ELECTRIC FEE
r�
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE'
MECHANICAL FEE
'
FEES PAID:
'
ALTERORADDTOMECH.
Date ReCel t#
P
-
MR HANDLING UNIT ITO 10,000 CFM)
•. SUBTOTAL:
MR HANDLING (mTr (OVER lE,000cFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
-
HEATING UNIT (TO 100,0(() BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTO
TOTAL:
VFNI A11ON PAN (SINGLE RESID)
ISSUANCE DATE
e
PAIC1
d�jV a �yyV
�^..
oars
ISSUED BY.
BOILER -COMP OTT' OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
Owner or authemced agent Date
TOTAL:
OFFICE COPY