20926 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingNote I Identification CL% n rr-� r PERMITNO.
Building Addrem: ear+ ` ,n 20926
04 sem-
wner.,/mss: one:
�, �Sdf �, 9\ C,CC1� �j 1 CITY OF CUPERTINO-BUILDING DIVISION
Con'ract.0^� LI APPLICATION/ PERMIT U K)rL
BUR.DINGELECTRICALPLUMBING-MECHANICAL CATFOORY CONTROL N
Architect/Engineer. LIB No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PLUMB latcri
Address:
Thi ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE (,(]
I hereby
a(flrmthat lam Ocmersunder inessadProfehapter9de,and APPLIANCESRE9DENML JOB DESCRIPTION
In ease I Section force of DIefaeon 3 olthe BuYneesand ProfessioneCode,and m
license I.to full farce andPANELS y., ,
License Clam Lie.If
Data Rev wkupo-kis
Contnttor V
ARCHITECTS DECLARATION 201-1000 AMPS
flz I understand my plans@hall be used as public records. OVERIOOOAMPS SQ.Fr.FLOOR AREA SM.FT.
Llmnud Profeashmal SIGNS ELECTRICAL
r
OWNER-BUILDER DECLARATION es SPECIALCIRCUIT/MISC
0 following
.son.ffi.that ction7 xemptfrom the Contrattorb License Law for the qqqqqq followingrescan.(Sectionrn)tto BusinessandProfessions Code:Any city or
� muntywhkh rcqulrcsa permlttommttvct,alter,Impmve.demoLLvh,arrepalr T�P'METER 0 LE INST.
a any structure prlarta its Issuance,aisorequlrestheappllcant foreuch perMtto
4 POWER DEVICES
E U Bina actors statement La that he t licensed pursuant it the pon 70101 of the
O
SOSContractors License law(Chapter 9(commencing will Settlors 7000)of Dlvl-
Yon3afthe Bu.nmand ProfewtomCode)orthathelsemempttherefmmand SV.'Ed'WNG POOL CTRIC VALUATION
6 5 the Istel,for the Akged exemption. Any violation of Section 70315 by any O ETSSW ITC
O� appBcanl(on permit subjettaheapplkanttoa civil penalty of oat morethan L �—
$ five hundred dollars($500). NEk1PIIJENTjALWLECSTORIES TYPE CONSTRUCTION
�n I a@ owner of the property,or my employees with wages as their sole
pcnsatlon,wlllduthe work andthestruchom is not Intended or offered for
sak(Sec 7064,Business and larofeseioru Code:The Contrecto(.Wcarue law
$ does not apply to an owner dproperty who build@ orlmprovn thereory and OCC.GROUT' RES.UNITS
EE who doesauchwork himselforthragh hi@ownemployee@,pmvWed that such
improvement@ am not Intended oroffered fm ole.If,howevegthebullding m O
Improvemontis@oldwithlnoneyearofcompletb theowner-bulderwlll have
the burden of proving that he did net build or improve for purpose of sak.). QTY. LUMBINd PER FEE FLOOD TONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANC
contractors to corotrvtt the project(Sec 7064,Business and Professions Cade:
The Contractor'@ License law does net apply to an owner of property who
builds or Improves thereon,and who contracts for such ptojects with a ALTER-DRAIN -W
og6.ctor(.)licensed pursuant to the Contractor's Lt...Law. FEE SUMMARY
LJ I am..,.pt under Sec B&P C for this rcawn BACK FLOW OTFLT.DEV] E
DRAINS R ROOF,AREA,COND. SANITARY Y N
. Owner Date RECEIPT M
WORKMAN COMP aT ION DECLARATION FIXTURESPERIRAP SCI400LTAK Y N
❑I hereby affirm that I have @ cemrtlficonsentself-inself-insure,te a(consent to self-insure,ora RECEIPT s
38M,UbC.) S of Workeni Comperuatlonluurancema certifkd copytM1ereof Oise. GAEA.SYSTEM.1 INC4 OUTLETS PARK FEE Y N
3800,Lab
Polity M DING DIV
GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEE
an
copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy is(Iced with the city Inspection division.
CERTIFICATE OF ECMFr10N FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA 20OFr. Date Remi t#
(Thlswdionneednmbecompletedifthepernr tisfmonehundreddollan
(SII0)nrless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certifythat In the performance o(<hewmk forwhlch this permit bhated,ised,
I shall not employ any person In any manner so as to bemire subject to the WATIBi SYSTEM/TREATING
Worker.'Compensation Laws of California.Date PAID
—
Z Z Applicant NEW RESIDENTIAL PLMB. SQFP, Date Recei t#
Z NOTICE TO APPLICANT.If,after mak!ng this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
~ N Code,you must forthwith comply wlthsuch provishmi.r this permit shall be
W > deemed revoked. .IML12ING FEE .�
IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE t 5-0
I hereby afermthat therelea construction lending agency for the perform- ELECTRIC FEE
7 Z ance of the workfor which this permit is busted(Sec.3097,Civ.C.) TOTAL:
C1 O I<ndcea Nana PLUMBING FEE
LL Lender'@Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certitythat l haveread this application and Yalethatthe above information
1 I.corrett.I agree to comply with all city and county ordinances and Yate laws PERMIT ISSUANCE PEES PAID:
>. N relating to building construction,and herebyauthorixe representative.of this
city to enter upon the abovementioned property for irmpection purposes. ALTERORADDTOMRCH.
2 (We)agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
V against BabNt cigmentn,".a.cl expenm khmayinanywayacarue AIR HANDLING UNIT(r010,000 CFM) SUBTOTAL
against sal in ronsarye grantln this
Cl` AIRHANDLINGUNIT(OVER10,000CFM) CONSTRUCTION TAX
gra pleat ractom to ExHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA DISCLOSURE
Ill the applicant or future building panbtore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date
material as defined by the Crtl
upem Municipal Code,Chapter 9AZ and the Recei t#
Health an
Safety CodeSection 25532(.)7 HEATING UNIT(OVER 100,(100 BTU) TOTAL:
No
Rill the applicant Mbam building rampart use equipment or device. VFNRLATION PAN(SINGLE RESID) ISSUANCE DATE
which emit havrelou.air contaminants as deftned by the Bay Area Alr ,
Quality Management District? BOILER-COMP(311POR 100,000 BTU) ,a
4Yea qNo
the 21htve rescithe hazaMoua material,requiremcnb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) t to Ina
vemia Health&Safety Code,Sections 25505,2593 and 25511.1
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL-MECH. SQ.Fr.
resporetbll ndl(y the o5mpantof the rryul ent.which mus be met
prior120704
to i c of a Ceruf fa Occu o at,at lam"
LI!' 9 I 1d ataa�gaµaw
e a ihor!' - Date
IOTA L: ISSUED BY:
OFFICE COPY