20235APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification q D/
Building Address:
PERMIT NO.
l s r CA
20235O
_I
caner e
f 16-7 to
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APPLEcATrMTM9MrrAT =A
r q O
7 -I
Contractor's Name: Lie. No:
BUILDING -ELECTRICAL PLUSIBING-MECHAMCAL
CATEGORY CONTROL N
Arthitet/Englneee Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PFRMIITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ia
IMrcbctleu,mthatlamecen3.(theunder provisions offcgdmsCd,.menc
3ofthe Businesaand ProfesslonsCode,and rtry
IngwRh Sect ion to. and
license Is In s form and tfect,
License Chm
APPLIANCESRESIDENfIAL
]OB DESCRII'170N
PANELS
\
Contk.#
Date Contractor
301-I0DOAMPS
ARCHITECPS DECLARATION
I understand my plans shall be used as public records.
II
OVER 1 ODO AMPS
I
SQ. Fr. FLOOR AREA
$/SQ. Fr.
SIGNS ELECTRICAL,
Licensed Professional
SPECIAL CIRC T/ LSC
OWNER -BUILDER DECLARATION
I hereby affirenthat I am exempt fromthe Contractor's License Law for the
TEMP, ME LEI
following reason. (Section 7MI.5, Business and Professions Code: Any city or
county which requires a permit to comtruct, altar, improve, demolish, or repair
.eystm=. prior to its exuanee,abo requires the applicant for such permit to
file a signed statement that be b licensed pursuant to the provblo. of the
POWER DEVS
SWIMMINGL C
OUILETSSWITC ES
NEW RESIDENTIAL ELECTS SQFr.
Contractor's License Law (Chapter 9(commencing with Section 7000)of Divi-
slon3 ofthe Buslnessand Profe.lo.Code) orthat he bexempt therefic d
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not room than
fiv ed dol am(g.5DO).
as owner of the property, or my employees with wages as their sole
VALUATION
STORIES
TYPECONSIRUCTION
penaatlon, will do the work, and the structure is cot intended or offered for
ie (Sec. 7044, Business and Professions Code: The Contractors License law
does not apply to an owner of property who builds or improves thereon, and
who doessuchwork himeelforthroagh hisow.employees, provided that such
OCG GROUP
RIS UNITS
TOTAL:
Improvements are not intended oroffered forsale. If, however thebuilding or
Improvement Issold withinomeyearofcomplebontheowner-builderwiil have
Fenenofpmvingthat he did not build orimprove for purpose of role.).
asowner of the property, am exdmively contracting with Ilcens d
.it. urs to mcc moithe project (Sec. 7044, Business ami Profesalo. Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
Contractor. License Law don not apply to an owner d property who
Wilds or Improves thereon, and who contracts for such p(njet. with a
punuust the Contractors License Law.
off am
LJ I am exempt undo B & P C for this reason
ALTER -DRAIN& VENT -WATER (PA)
FOUEE SUMMARY
B/sCIC FLOW PROTECT. DEVICE
FLUOR, RDOF, AREA, GOND.
SANITARY RECEIPT It
7DRAINS
WORXM COMPENSATIONDECLARATION.���.�P
❑T hereby affirm that I have a cenificat t consent to self-Iname, or a
certificate of Workeri ComperuzUon Imuran rat nrtifiedcopythemof(Sec.
3800, lab G \
FD
SCHOOL TAX Y_ N_
RECEIPT N
GAS F.A. SYSTTM-I ING4 OUTLETS _
PARK FEE Y N
RGCEII'T N
policy Y
Com y
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DI V ISI ON FL LS
Cerartificd copy is hereby furnished.
r-1 Codified copy Is filed with the city inspection dividon.
CRIEASEANDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SANRARY-STORM EA 300Fr
COMPENSATION INSURANCE
(rhissedlon need not be completed if the permit efor one hundred dollars
(5100)one.,.)
I corti(ythat In the performance of the work forwhich this permit Is bsmd,
Date Recej t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
WATER SYSTEM/TREATING
1 shall not employ any person in any manner se as to become subject to the
Werkcri Compensation laws of Caufomfa. Date
PAID
NEW RESIDENTIAL PWB. SQ.FT.
Applicant
NOTICETO APPLICANT: 11, after making this Certificate of Exemption, you
should become subject to the Work<n' Compersatlon provbio. of the Labor
Date Remi t#
TOTAL:
BUILDING FEE
Cale, you rswat forthwith comply with such provide. mthb permit shall be
deemed m.W.
CONSTRUCTION LENDING AGENCY
Iherthe aorkforwhthem bacomwctronssu tendingagency 097,Ci.C.) perform
amu of the work for which this permit b issued (Sec. 3097, CIv.CJ
lender. Name
lender's Aadrtss
SEISMIC PEE
t
ToraL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
cmad mply wth alicat andnanal
Icrect. I hatI agree toyordinances and gate laws
iscorrect.building comply andcity
PERMIT ISSUANCE
FEES PAID:
herob .whoice repnrentatWeate
relating to building roabove- on, end hereby authorise rcprexnpurposof this
cit Wentere alae, Indemnify and forW ectl it a
Y P° property P purposes.
(We) agree to save, Indemnify an d keep harmicas the City of Cu yway. tino
against liabilities, judgments, cos.and expenses which may In any wayaccrue
lime
ALTER ORADDTO MECH.
Date Reeeipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against said City In consequence of the Branding of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUS"r HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAM R DOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date ReCci [#
Wit l the applicant or futum building occupant store or ha rad le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
IleallhandSafetyCode 5ntlon 35532(a)7
F1 Yea MNo
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dist rid?
4 Ycs n No
Mvereadthchaear7iousmrteriab requirements under Chapter 6.95 of
HEATING UNIT (OVER 100,000 BTU)
_
VENTILATION FAN RFSID)
ISSUANCE DATE
(I L
MAY `x at IJy�
Cjty. of (!lJnort�RR
BOILER -COMP (3111' OR 1M NU BTU)
BOILER-COMP(OVER100,000 BTU)
the California Health & Safety Code, Setiom 2 5(15, 25537 and 75534. I
understand that it the building docs not currently have a tenant, that it is my
NEW RESIDENTIAL MECH. SQ.Fr.
responsibilitytonotifyt oc pant ofthe requirements which must be mot
prior to issuance c Ific cof Occupancy.
�1q.Ja��'��s���
ISSU'D BY, �V('/v�Klw�✓M'"�4'
jr-mer or authorized agent Date
TOTAL:
OFFICE COPY