20263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
" Hui-Iding Project Identification PERMIT NO.
0.11SLing Addrem: f7 20263
/�
; ante: one G A
� ;, .1//U.E7� CITY OF CUPERTINO-BUILDING DIVISION
CCV;/rGNZ,'. TDNtKdaU ( L . o: APPLICATION (PERMIT
A�S,�- -ELECTRICALPLUMBING-MECHANICAL
AL CATEGORY '—`
CONTROL aBU
BUILDING
Architect/Engineer.
Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. 1 ❑ PLUMB LE11❑
LICENSED
ICENSED CONTRACTOR'S DECLARATION
PFRkTISSIANCE
Ihereby rmthat lam licensed underprovisions
ofCh r9(rommenc APPLIANCFSRFSIDENML
JOB DESCRIPTION.
InhSodion fDiv3oftheBminessand ProfessoeCode,and my
license 1.1.hill force and effect.
,
PANELS
License Clam_ Lic.N ax-
Ur
Date ContractordoR/d '10, p1-1000 AMPS
ARCHITECTS DECLARATION
re 7. •I understand my plans shall be used as public records. OVER I ODO AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
Licensed Professional SIGNS ELECTRICAL ,
<CtPOWNER-B UILDER DECLARATION '
I'n td SPMlALCrRCUIT/MISC
i„ J lherebyafflrmthat lam exempt froenthe Contradorb License law for the -
70 t- following reason.I5mlon 70315,Business and Prefesalons Cade:My city or '
county which requlresa permit tomrstrud,alter,Improve,demoliskorrepair TEMP.ME17]t OR POLE INST.
F4 n structure price t its Issuance,alsorequires the scant for such mit to
Q any si p or o pp per
Ole a signed statement that M is licensed pursuant to the provisions of the POWER DEVICES
3 G Contractor's License Law fChapter9(commencingwith Section 7000)ofDivi. SWIMMING POOL ELECTRIC VALUATION
slon3ofthe Businemand Proemlons Code)orlhathebexemP therefromand
alleged
g 65 thebarbfor thermit subjects
exemption. Any ttola civil
of Section nor m eany . OUILE'ISSWITCHESFlXTIIRES s
appISI O five hunt fordred collars $5M.bthc applmantmadvil peoaltydnot more than
$
five 1,as owmr of
pro NEW RESIDENTIAL ELECTR SQ.FT. STORIES 7Y PECONSTRUC'I'ION
.. ❑I,as owner of the properly,or my employees with wages r their dole .
s.7�¢ compensatmn,wmaothe work and the strudurc ie nos Intended or o0enedfar 'U
D cele(Sec. pply to a nowner f grope ty Co builds or I p eves License Law L a
��,,� $ docs na apply to an owner of property who builds or improve therxon,and
^ who doessuch work himself or through hisown employees,provided that such _ OCC.GROUIa RIS.UNITS
Improvements are not intended oroffered for sale.If,however,lhebuilding or .TOTAL: 2�
improvement bsold withmoneyearofcomplelloq theowner-bullderwlll have
it rdenof proving that he did nor bulla or improve for purpose of sale.). QTY, PLUMBING PERIT FEE FLODDTDNE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANSE
contractors to construct the project(Sec 7044,Business and Professions Code:
The Contradorb License Law does not apply to an owner of property who ALTERARAIN L(EA) �•
Wilds or improves thereon,and who contracts for such ped.Rnjwith a \
A,IBT.d.r(s)uansed pursuant to the Contractor.License Law. BACK FL" EVICE FEE SUMMARY
LI I am exempt under Sec. B 4 P C for this reason OUTSIDE FEES
DRAINS FA GOND. SANITARY •Y_ N_
Owner Drte .1 RECEPTa
WORK MAN COMPENSATION DECLARATION FIXTURES PE SCITlX1L TAX YN
01 hereby affirm that I have a certificate of consent to.e141nsure,ora RECEIPT 8
cenlOuteof Workeri Compev tlonlmumnmoramAif[Mmthereof(Sec.
3800,Lab C.) SpA. ' Il7l PARK FEE Y_RFLE4I N
N
Policy# EA, VER )'
Com any ' BUILDING DIVISION FEES
[�cert[fled copy b hereby furnished. R D LW I' oR PLANCKECK PEE
OCedlfied copy b filed with the city inspection division. `
CERTIFICATE OF EXEMPTION FROM WORKERS' G E PAID
COMPENSATION INSURANCE gAMTARy-STO POET Date RCCCIpt#
(This sectim reed not W completed if the permit is for one hundred dollars
(9100)mless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of the work for which this permit Is Issued,
I shall not employ any person in any manner so ns to become subject to the WATPRSYSITM/TREATING PAID
Workers Compersationlaws of California. Date
Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Racei t#
ZO NOTICETO N'PLICANT:If ,after nuking this Cedl(kate of Eiemption,you
should becomes imbject to the Workers'Compensation provisions of the Labor . TOTAL:
cc N Code,you=at forthwith comply with such provisions orchis permit shall be BUILDING •
IU > deemed revoked. i
Q.
is . CONSTRUCTION LENDING AGENCY SEISMIC FEE
T hereby affirm that there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE -
.7 Z arcs ofine work for which this permit is issued(Sec.3097,Cls.C.)
V O lander.Name t PLUMBING FEE
F- Landers Address QTY. MECHANICAL PERMIT FEE
C• w lceniythatlh.vareadthisappuati....dd.tethattheaboveinfomution MECHANICALFEE
4 bcorrect.I agree to comply with all city and county ordinances and slate laws PERITFISSUANCE FEES PAID:
>_ 0. to building construction,and herebyauthor[ureprisentativesofthis
N city to enter upon the aWvc-nuntioned property for Inspection purposes. ALTERORADDTOMECH.
Z _
(We)agree m cove,indemnify an d keep harmless the City of Cupertino Date Reccipt#
O agal blllti jrdgmet Pel,an xpansro which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago st id C In cont ueneof granting orthls permit. - -
S'9�� AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX'
Signature Plcam on r dor, - Date IXHA(ISTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant re future building occupant store or handle haeardous HEATING UMT(TO 100,000 BTU) Date Recce t#
materbl as defined by the Cupertino Municipal Code,Chapter 9.I2,and the
I lea lth and Safety Coda Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes ri No
Will the applicant orfuturebullding occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardom air contaminants as defined by the Bay Area Air
Quality Ma rugement Dist rid?-, BORER-CAMP OHP OR 100,000 BTU) -
n Ycs, ❑No
- `{'have read the h.urdoua material,requirements under Chapter 6.95 of BOILER-COMP(OVER IW,OW BTU)
the Californi c hk Safety Code,Sections 25505,7533 and 25534. I �, 7
understa t sbut[ doeso currently have a tenant,that It is my NE9RFSIDEPHALMECA. SQ.FT. s-
respo it i o iyt pant therequiremem.whichnwstbemot ^n
pdor o n Ce ific sof crupancy. - •.• ^sl!t
ncr or au once a Date I
TOTAL.: SSUEDB
OFFICE COPY