20454 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuIldmR Prued Identification PIRNITNO.
Building A 20454
01 N+:e ` _ one. A
WI CITY OFPLICATION If DINGPER DIVISION
C m a or'sName: e.No: APPLICATION /PERMIT
rchlte / neer. BUILDINGL
ELFCTRICAPLUMBINC-MECHANICAL CATEGORY CONTROLa
Lk.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PLUMS M�H
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provislons of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ing with Section 7000)of DWision3o(the Business and ProfeaslonsCode,and my -
Ilcense is-a full nd effect. PANELS -
Date la Contra
Date Contractor
ARCHITE A 201-3000 AMPS
pQ±0 C,1 understand my plans shall be used a public records. OVER 1000 AMPS SQ.FF.FLOOR AREA f/SQ.FT.
E se
`j Licend Proem
fbnal SIGNSELECTWCAL 1
QQQ6�QLlu7 fBOWNER-BUILDER DECLARATION $pF-CULCIRCNT/MLSC
7 a 1herebyarm thatI am exempt from the Contractor's License law for the
following reason.(Section 70315,Business and Professions Code:Any city or
FH countywhkhmquimsaper tW.Mtruct,alter,impmve,d..Iish,ormpalr TEMP.M OR POLIW.
sa any at.1gred t tanst lu that
is disc sed poslheapto thelfw ist..of t e pp D i
O V co a signed statement that he t r9(our pursuant to the proWlons of the
1-,�OwG Contractor's License Law(Chapter9(mmmancing with Section 7000)o(Divl- L • BC VALUATION
S Bion 3o(the Business and Profession,Code)mthat he is exempt therefrom and
the basis for the alleged exemption. Any viulatlon of Seetiun 7031.5 by any OL7hf)W*H*E�FJuR ES 2�O
appllmntfor, a permit subjects the a pplicant to a civil per,lty of not more than
five hundred dollars(xiW). . ftES[D ELFCTR SQFI. STORIES TYPE CONSTRUCTION
�E77 7 Q m1,as owner of the property,or my employees with wages es their ale
mpenmtion,wfId.the work and thestruM.is not Intended or offered for It
q cele(Sec.7at4,Business and Pmfemlmu Code:The Cootractols License Law
F$� don not apply to an owner of property who builds or lmprwnlhercary rad
who does such work himself or through his own employen,provlded thata OCC.GROUP RES UNITS
knprovements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvementisnoldwithinoneyearofcomplmiokthe wner-bullderwIII have
ti�rdenof pmving that he did no build or improve for purposeo as .). QTY, INC PERMIT FEE FLOODZDNE APN
LJ I,as owner of the property,am exclusively mntracHng with Ilm— pEg(,(IT I ANCE
contractors to construct the pmject(Sec.7064,Business and PmafemionsCode;
The Contractor ff Lkeuue Law does not apply to an owner of property who ALTER-DRAIN A,VENT-WATER�N
Wilda or impmves thereon, and who contracts for such pSojects with a
ctFEE SUMMARY
ro�lpaw(s)licensed pursuant to the Convacta/a License Law, BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B&P C for this masonOUTSIDEFFES
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Date RECEIPT M
WORK MAN COMPENSATION DECLARATION MT.URES.PER TRAP SCITOOL TAX Y N
❑I hereby or( m that I have• fmum to of consent m pythemf or• ��.N
certificate o(Worken'Compensatlonlnsurana ora certified mpythereof(Sac. GA PA.SYSTEM-I INCA OUTLETS PARK FEJT Y N
33lic lab C.)
Policy M GAS F.A.SYSfEM.OVER 6(EA) DING DI N
Com any - BUILDING DI VIRION FOES
Certified copy is herebytumis city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ad
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recel t#
Rhls sectionneed not be completed If the permit is(oraoe hundred dollars
(51I mdifyth - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Iwrti/ythat In the performance of thework larwhich this permit is Issued, —
=LIshall not empi y n In any manner m. scD lib' c
.n Cc tl ws of Glffee J WATER SYSfGhf/TREATING
O Z Applicant dl/ (/ � PAID
—
0
O NOTICE TO A I,a a this ertff ateo mptlon,you
NEWRESIDENTIALPLMB. SQ.FT. Date Recei IN
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such pnwislons orthis permit shall be
W > deemed revoksd.CONSTRUCTION LENDING AGENCY BUILSEISDING
FEE
E L
CL Iherebyaffinnthat thercisamnstactlon lendin (or the Roan ELECTRIC FEE
gagenry pe
I L16
M Z anre of the workfor whkhthis permltisisaed(See 309J,Civ.C.) TOTAL:
02 LardehName PLUMBING FEE
LL ~ Lendcr'e Addre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcedlfythatl hawmadthisappBeationand stalethatuheabovelnformation
is mmect.I agree to comply with all city and munty ordinances and stale laws PERMRISSUANCE FEES PAID:
} a relating to building mnstmction,and hereby authorize mpracrtattvn of this .
W d to entero n the above,mentioced forInspection ALTFAORADDTOMFCH.
~ Z
city P�rt3' wRoper Date Recei t#
V _. (We)agree to cove, tot,. .an d keep harmless which the City of Cupertino
against said City in consentgmetof the
expenen which may In anywayanmue AIR HANDLING UMT(TO 10,000 CFM) SUBTOTAL'
against said City In consequence o(the granting of this permit.
AIR HANDWNG UNIT(OVER l0,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT DO 100,0DO RTU) Date Reeef tic
anterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hwlthand Safety Code Secu.r25532(a)7 HEATING UNIT(OVER 100,000 BTU)
RPAR ' TOTAL: L—)a
Yes No
ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) is$ ATE
which aManagement
hazardous
District? BOILER-COMP OTO'OR I OO,DM BTU)air contaminants as defined bythe Bay Area Air
Qualil N
r
1
4 Yn 9No
Cl read the hazy ous rnaerisis requirements underChapter 6.95 of BOILER-COMP(OVER104000 BTU) � ��aa�aa ja�p 1�9tl
the Glifemia health&Safety Code,Sections 25505,25533 and 25536.1 AM.�CY�1w W1O1
understand that ifthe building don na mrzenlly haveatenanL that ltismy NEW RESIDENTIAL MECH.
responsibility to notily the occupant of the requirements which moat be not �G Q�Cunaa{inas
priorto Issuance of a Certificate of Ocmpanry.
n
Owner or authorized agent Data ISSUED BY..
TOTAL:
OFFICE COPY