20646 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER.MITNO.
Building AddrO
IIu504I 20646
8 '6%V_0 CfI6?61 e'137 CITY OF CUPERTINO-BUILDING DIVISION
cantr,G ; Lic.N. APPLICATION / PERMIT ��q O
BUfLDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Archuret/Enginesr: Lic.No:
OTY ELECFRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERNUTISSUANCE 11 C(7 M � � 1:1L at I a CONTRACTOR'S DECLARATION
I M1ercby affirm m thatm llceneed under provisions of Chapter9(rommmc- APPLLANCESRESIDEFITIAL JOB DESCRIPTION
IngwithSmlon7000)of Div6bn3ofthe Businessand PmfessloneCode,and myPANES /mak
license la In full force and effect. CC�� �1�L
License Class Conte pew ` ,^\,-o__ a.
Date Contractor 2011000 AMPS �^'`VJ �7.�]�
ARCHITECTS used
public
OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ors O I understand my plans shall be used a public records.
(Cj Licensed Professional SIGNS ELECTRICAL
¢' OWNER-BUILDER DECLARATION SPECIALCBRCUIT/MISC 1
H � Ihembyaflrm thatlam exemptfrom the Contractor'.License Law for the ((
p 9L F following reason.(Section 70015,Business and Profemions Cade:Any city or TEMPMFITRORPOLEINST
countywldch requlresa permit toromrrud,alter,Improve,denulish,oreepalr _
Fy'y g.a anystmnure prior to its Issuance,also requires the applicant for such permit to
E uM a signed statement that he Is licensed pursuant to the provislom of the
FSO^'
Contractor's License Law(Chapter 9(commencing with Section 70W)of Divi- 1 - tNG IDOL ELECfRC t t
VALUATION
ti�Op� debasison 3 for
Business and Pemption. Any
hat ion of exempt tMrefromany -
3 the bash for the alleged exetsthea Any t to acivi of Section not m by any b otIILEIS6WIICHEsFr° CXJ1 (k "
0 appBant(ora permit subjects the applicant roa dull penalty of eta more than _
gg dred dollar(SSgB.
Rtt NEW RESIDFMIAL EIEC SQ.FT. STORIES TYPE CONSTRUCTION
7 6 a owner of the property,or he employee with wages r thele sok
mpensmmn,wuldess andotthe rk,Pr and thes Code;ure The
Contot rendedactor orcensed for
Law t
❑ le(Sec. ppy Badness and f property Cade:The Contractors License Law
fd $ doe not apply to work
owner of property who n aids or improve thereon,and that such OCC GROUP RES.UNITS
0.0.
who doeents soch worn Intelf or dedorughhisownemployees,
er,the uildingor
Improvementsarerat Intended earofco pleloe.ILha era Elder ilI have TOTAL:
unprovement bnold withinoncycarofcomplelion,theowner-buuderwlll have
t"rdenot proving that he did not Wild or bnpmve for purposcafsale.). Q7y, PLUMBING PERMIT FEE FLOOD TpNE ApN
LJ I,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7004,Business and Profeasims,Code: I (�
The Contractor's License Law doe not apply to an owner of property who
build.or Improves thereon,and who contracts for such p(ojects with a ALTER-DRAIN Ne VENT-WATER(EA) GO
,dt ctor(q licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI f am exempt under Sec. B k P C for this mason
I DRAINS FLOOR,ROOF,AREA,COND. cc SANITARY Y_ N_r
• Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTIIRI:S PER TRAP n O6 SCI IDOL TAX Y_ N_
❑1 hereby a(flmn that I have a renlecate of consent to self-insure,ora 4 RECEIPT N
mnificac.fWorke CompcmMhn Isuranceara certified copy thereof(Sec. GAS EA.SYSTEM-1 INCAOII7LEI5 '�00 PARK FEE Y N
3800,Lab C.)
RECEIPTN
Policy N GAS EA.SYSTEM-0VER d(EA) BUILDING Divi SION FEES
�m any
�CeAllied copy B hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WOR K ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIDRM pA 200FI. Date Recef t#
(TM1issedkm nee not be completed If the permit V forone hundred dollars
($10G)or leu.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner m m to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Revel t#
Z 0 NOnCETOALTLICANT:Ilaftermakingthb Certlirateaf Exemption,you
should become subject to the Workers'Compermtbn provisions of the Labor TOTAL:
CCN Cade,you most forthwith comply with such provlsloru or this perrrdt shall be BUILDING F t�
W F) deemed revokcd.CONSTRUCTION LENDING AGENCY SEISMIC FEE L O
11 I hereby affirm that there V a construction lending agency for the performELECTRIC FEE
7 Z an.ofthe work for which this permit b esue(Sec.3097,Civ.C.) TOTAL: aaw
02 Lender.Name PLUMBING FEE
U. F Lander.Address QTY. MECHANICAL PER FEE MECHANICAL FEE
W I ceNfythat l have read thbappucatbnand date thatthe above Information
0
CL iscomect.I dgree to comply with all city and county ordinance and date laws PERMITISSUANCE FEES PAID:
rel at Ing m=Ion,and hereby authorize representatives of this
N to enter upon above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)age tome,lode an d keep harMem the City of Cupertino Da[C Rxeipl#
re
V against liabilltle," ,. , sand expen which may inanywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against mid I con cc of the gra g of this permit.
_ _ AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
g Ap Irani/ antrador Dain IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBont or future building occupant More or handle hazardous HEATING UNIT(TO 100,010 BM Date Rtxci t#
matnrul as defined by the Cupenina Munidpal Cad,Chapter 9.12,and the ^I
Healthand Safety Code Settiun 8532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: I Sl
❑ Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Arca Air
Quality Management Distrld7 BOILER-COMP OEI'OR 100,000 BTU) �1�
I—I No �•C
ve mad the a oils materials requlrcmnnts under Chapter 6.95 of BORER-COMP(OVER 300,000 BTU) - JUL ��
e California Heal &Safety Code,SMlom 8505,8533 and 75530. I JU 199
understand that It bulletin na current M1ave a tenant,that It is my NEW RESIDENTIAL MECH. SQ.17. U
respoeibllitymn d4,the cu nt of them remeniswM1icM1 must be met
prior to Lssuan aCe fl ofOmpa
. � h!Of CUDBNf�I1_R0��a ,
n nor rued age Date TOTAL: ISSUED BY: "M X-C, 'y
OFFICE COPY