20164 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proea Identification _ PERMIT NO.
Buaki ng Address:
20164
ners ante. one:
CITY OF CUPERTINO-BUILDING DIVISION
Lac.No, �j APPLICATION /PERMIT
Oa 7 BU)LDINGELECTRICALPLIJMBINGMPfHAMCAL CATEGORY CONTROL M
Architect/Gglnee. L'c.No:
Q'IY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PF'RMITISSUANCE ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am llcen d under provblons ofChapter9(commenc APPUANCES-RESI)ENTIAL JOB DESCRIPTION
'ngw'lhSectton7000)of Division3ofthaBuanessand Profe&aonsC°de,and my
license is I.f.11% PANELS�d
LkcmaGassGL'c.M 165:�D9
Date Contractor UP TO 2DO AMPS
ARCHITECTS DECLARATION 701-10DOAMPS
re0 2 I understand my plam shall be used as public record& OVER I OOO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CO
(� Licensed Pnefera'onsl SIGNS ELECTRICAL D IN
< - UILDER DECLARATION A L E
In OWNERBSPECIALCIRCUIT/MISC
.2—
Iherebyaf0rm that].mexemptfrom the Contractors License Law for the PATER
following reasmn.(Section 7031S, ea Businand Professions Code:Any ty cior
� t. TEM['.METER OR POLE INS!.
,� anycoustmahme pryulresa permit ntommwcl,es the provgaemofish,ormitto
any a signeretatemenIts luuanegaWrequ pursuant
applicant rovisoor suctib pemdte POWER DEVICES
Ole o signed statement that he V licensed pursuant to the proWlons of the
O S Contractor's License Law RN.pter 9(commencing with Seaton 7000)of Div'- SwT
'; alon3°(lhe Bualnemand Prdenlons Code)orthat hebeumptthere(romand w'MING POOL ELECTRIC
G tM1e bash(or the alleged exemption. Any violation of Section 7041S by any OUTLETS-SWITCHES FIXTURES
applicant fare permit subjects the applicant to a civil penalty of net more than
five hundred dollars($SM. NEW RESIDENTIAL ELECTR SQ.FT, STOR12B TYPECONSTRUCTION
�n
1-11,as owner of the property,or my employees with wages as Iheir sole
< compensation,will do the work and the structure is not Intended at offered for
O as le(Sec.7014,Business and Pmfesslons Code:The Coomdoes License law
$$ does not apply to an owner of property who Wilds or Improve,thereon,and OCC.GROUI' RFS.UNITS
who doessuchwork himself or through his own employees,provided that such
Improvements are not intended oroffered fomale.If,however,thebuilding or - TOTAL:
Improvement issold within oneyearofcomplalon,the owner-W IMerwlll have
t"rden of proving that he did net build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE p(pOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
Wilds or improves,
thereon, and who contracts for m such pru)ewith a FEE SUMMARY
c
do 8)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT,DEVICE
LI I am exempt under Sec B k P C for this reason
DRAINS.FLOOR,ROOF,AREA,GOND. SANITARY Y N
Owner Data re or
RECEIPT
KM
WORAN COMPENSATION DECLARATIONFD(TURE
[—]I[—]I TRAP SCHOOL TAX Y N
hereby affirm that 1 have a ceklliice[e of consent to seythen RECEIPT a
certlflcate of Worken'Compensatlonlnsuranmwacertifled copythereof(gee. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.I .r(/ RECEIPT 0
Pollryp WC D 7'7t�Cm nv. u0i�aii/ r�-,rr..osis GAS- BUILDING DIVISION FEES
oS FA
FICer�Cedlfied copy 6 filed-with
tu'ea plc y herebytd. - GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
b tthe he city
tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PALO
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 7BBFT Date Rece) tIl
(I'hlexction need na he completed If the permit a(carom hundred dollars
($100)orlem.) WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
I metifylhat in the performance°f the work forwhlch this permit is Issued, —
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of Cal fom'a.Date PAID
licant
Z 0 NOTICETO APPLICANT.ILafter makingthis Certificated emption,you NEW RESIDENTIAL PLMB._SQ.FT. Date RCtxl tN
H should become•ubjMmthe Workenm
'Compeatlan provlaons ofthe Labor TOTAL:
cW Code,you=at forthwith comply wllhauch provisions or this pears shall be
LU > deemed revoked. BUIL12ING FEE
Q. C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction looding agency for the perform ELECTRIC FEE
D 0 ance (Se
of the work for which this permit is issuedc.3097,Civ.C.) TOTAL:
U ender9 Neme PLUMBING FEE
LL F Lrndera Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l mrtlfythat i have read thlsapptiotionand aatethal the above Information
IL iscomet.Iagree tocomply with all cityand county ordinancesand state laws PERMITISSUANCE FEES PAID:
T relating tobullding constmctlm,end hereby authorlercpresentaHvee of th4
U) city to enter upon the above-mentioned property for Impaction purposes. ALTFRORADDTOMECH. Date Reeei tk
Me)agme to save,indemnify as d keep harmless the City of Cu Nr1 mo
V against liabilities,judgments,mete and expenses which may In any wayamue AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
gam�jala Clly In consequence oe�/the gra nting dthla pemdt. AIR HA NDLING UNIT(OVER I QOW CFM) CONSTRUCTION TAX
a�
Signature of AppBcanU<a/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS R Ca DOLSrn Date MATERIALS DISCLOSURE
Will the defined bor y
future Cupertino
building ode, orheer le harardom HEATING UNIT(TO 100,000 BTU) Date Reeel tN
material m defined by the Cupertino Municipal Cods Chapter 9.1$and the -
H ralth and SafetyCod.Sectlon 75537(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No VEMHLATION FAN MID
Wlllihe appltantor lure Wildingompant use equlpmentrndevim ) ISSUANCE DATE
which emit haziNous air conomumna as defined by the Bay Area Air
�usilty Management District? BOILER-COMP OHIPOR 100.0(p BTU)
Y. No
T ve read the hazy cam materials requirements under Chapter 6.95 of BOILER-COMP(OVER i00,000 BTU) ,
the California Health A Safety Code,Sections 75505,75573 and 75534.1
undersuand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MEQ7. SQ.FT.
responsibility to notify the oaupant of the requirement.which most be met u
prior to L�uaannmuof a Certificate of Opav/pancy. .1. y v.71
etl
Owner or authorized agent Date LSSUEDO : �I.
TOTAL:
OFFICE COPY