20245 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
nuudln Pro cd Identifiur PERMTNO.'
Building Address' I
20245,
ere ameone: AMT=Tr5RTU9MTTrAT=
CITY OF CUPERTINO-BUILDING DIVISION
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trdo' Name: _ see. o APPLICATION /PERMIT - �—�O
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AW10('�C H•1.1NUILDINC-ELECTRICALPLUMBINGMEC}IAMCAL CATEGORY CONTROL M
Architectgieeer: BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address:7Uo PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I
hereby alfirm that l am licensed under provhlons of ChaPler9(rommenc APPLIANCES-RESIDENTIAL ]OB D[SCRB'fION '
Ingwith Section 700a fDivision 3 oftha B/uslnessa dProI sta Code,and my
liana is In to f re, dfeR-J•C' PANELS �� .. ,
Llansc �ss ic.N
Date ontnctor 201-1090AMPS UP TO 2N A105
ARCHITECTS DECLARATION
m I understand my plans shall be used as public records OVER1000AMPS SQ.PL FLOOR AREA . $/SQ.FT.
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ZF Licensed Professional � SIGNSELECTRICAL /(��� Ig' Nr� 1I^1
DI '.' 114
OWNER-BUILDER DECLARATION SPECIAL CIIRCNT/MISC :% 0 IL f.,., [.J
io.., '2 L herebyafBrmthat famexempt fromthe Contractors License Lawfwthe /7 L��aa p pp��
OZ a following reason.(Section 7031.5,Business and Professions Code:Any city or �P.METER OR POLE INST. ( e �1/E i./ B B T p...
p; F' county which requires a permit to ormtroct,alter,Improve,demoLLsh,or repair V T 1 V 1 E
'y 13
� any structure prior to its issuance,alao requires the applicant fh oraucpermit to
YOY POWER DEVICES V/V/9
K file a signed statement that he la licensed pursuant it the tion 700D)of
of the
m� Contractors License Law dP tis pter 9(commencing withSectionhammed andivi. rr
SWIMMING POOL ELECTRIC
06 slon3ofthe Bualneas and Professiaru Code)orthat he Vexempt lherc(romand `k •" /
X'•..1t the Wsb for the alleged exemption. Any violation of Section 7071.5 by any ^`
�r S _ OUTLETSSWITCIiFSFlX[VRES . ..
6,
applicant for a permit subjects the applicant toes civil penaltyof nes momthan
F, live hundred dollen($500). NEW BEERDENTIALELECTR SQ.FP. STORIES TYPE CONSTRUCTION
�j []1,as owner of the property,or my employees with wags as their auto
< compensation,will do the work and the structure is not Intended or offend for
' p sele(Sce.7064,Business and Podessioru Code:The Contractors Llaree Law
j$ does not apply to an owner of property who Wilda or improves thereon,and IR:C.GROUI' RES,UNITS
EE who doessuch work himself or through h+sown employees,provided that such
Improvements are net intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement Lssoldwithinoneyearofcompletion,tWo er-builderwill Wve ,
oAprrdenofpmving that hedid nmb„ndorimpmvef°rpurpose°fsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN .
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sm 7064,Business and Professions Code:
TW Contractor.Lt...Law does nes apply to an owner of property who
Wilds or Improves thereon,and who contracts for such pRojects.with a ALTER-DRAIN&VENT,-WATER(EAT -
"gIll�+ctr(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY
.L-•J 1 aom exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY 'Y_ N�
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Owner? - Date _
RECEIPT`p -
WORKMANCOMPENSATIONDECLON IIYNRF.S PER TRAP SIZE IDOL TAX Y - I'
I hereby affirm that 1 have a anlUate of consentsenttoto self-Insure,or a RECEU'f M
A to u(Wor mperwtlon>Iwuranaeracenifkd ropythemo((Sec. % GAS EA.SYSTFAI-11NC.60ITI1.E15 _D�/' PARK FEE - Y N
PollOO,Iab C.) //771 f///�G-'' .
CAS EA.SYSTEM-OVER 4(EA) BUILRECEDING
Co.Com an A NUILDING DI VISION FEES
�Ccrllfled cup I,h reby furnished. - PLANCIIECK FEE -
�Certdledcopy lafiled with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA 3(IO17Date Recei t#
(Thlsseetlon need nes be completed lithe permit later one hundred dollars
($10(D°rless.) WATER IiFA7FR W/VENT/ELFfTR ENERGY FEE Y_ N_
I mnify that In the performance of thework forwhich this permit is Issued, ,
1 shall not employ any person in any manner so as to become subject to the WATER SYSIEM/TREATING
Workers'Compensationlaws of California. Date PAID
C' Z Applicant - NEW RESLDENTEAL PLMB. EQ.Fr. Date Reeel t#
Z NOTICE TO APPLiCANT:If,after making this Certificate,of Exemption,you
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should become subject to the W°rkeri Compensation provaite fthe Labor TOTAL:
y Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
W > doem d revoked.
.CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihembyafflrmthat them baconstruction lending agency for the perform- ELECTRIC FEE
7 Z ancee,'.Nwork brwhichthla permitlaowed(Sec.3097,Civ.C.) TOTAL: 0 _Q
O O I<nder.Name PLUMBING FEE
H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I artifythatl have readthis application and statethatthe above Information
1 lacormctd agree tocomply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to building commotion,and hereby authorize representatives of this
city to entcrupon the above.rrcmioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z .Date Receipt#
(We)agree to ve,Indemnify an d keep harmiess the Clty of Cupertino
V agalnot I bilitl ,ju mems,C .k nd�xpenseswhichmayinanywayaccrue AIRHANDLJNGUNIT(TOIO,"CFM) SUBTOTAL: D
Id 1 _nsequ o Mgnmm of risco permit. Dv CONSTRUCTION TAX
O AIRF7ANDWNG IIIVIT(OVPR 10,000 CIM)
Slgwtu of Appli am/ Data E%]iAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
R OUS MATERIALS DISCLOSURE
I` Wi the applicant or future building occupart store or hand le huardous HFATINC UNIT GO l 00,ODO BTU) Date ReceI t#
mate las defined by the Cupertino Mu nicipal Cod,Chapter 9.1 7,and the O
Ilrel hand SnlctylOn 25533(a)? HEATING UNIT(OVER 100,000 BTU) ' TOTAL:
FI Yes - No �• .
Will the applla to
W” ing oecupant use equipment or devices VENTILATION FAN(SINGLE RESID) - 1$$UAtyAIGE DATE
whichemlthav us air on
as defined by the Bay Area Air
Quality Management D sl 7r(et7 BOILER-COMP(3E1P OR IOQOq BTM
4Ycs -915''�9''l{'`'Nu ��r s� y
havereaathe hest smatcrials requlrcments underCW pter g.95 of BOILER-CONP(OVFR 100,000 BTU) fy V 'T 9t�J
the Glifomia Helt &Safety Code,Sections 25505,25533 and 75534. 1
understand ait ebuildingdocsno mrmntlyhaveatenant,thutitbmy NEW RESIDENTIAL MECN. SQ.rT.
mib' t to r the occupa tofthe requimmentewhich must be met City of /ri)nprtino
'
ort s o/ niif/f('a cuparoy
Ow cr rauthodw a e Date - 155IlED UY:�) �
TOTAL:
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