20871 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification I PERMATNO.
Building Address: 20871
hers arm r.;
puTf H CITY OF CUPERTINO-BUILDINGDIV
rslo a �
C.Mr.doe.Name: Lie.No: APPLICATION 1 PERMIT
` V,e Q t_—: ' %W(- r3CV(-A Bl11LDINC E.ECTRICAI PLUMBING-MECHACATEGORY CONTROLaY tj I
Mchltcd/Engineer. Lie.No: L9
QTY ELECTRIC PEA IT FEE BUILDING PERMIT INFO
Address$\-A _ a f- PERMITISSUANCE r OG ^FZ1'
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Cha pier 9(crxrmmrAPPLIANCES-REERDENWL JOB DESCRIPTION
IngwlthSedlon 700)cfDWision 3oftheBuelneseand ProfessI.r.Code,and my I / ,rte t.- ` w
license is In full force and effect. PANELS 1 IFY`'l�'1 "�
W elk VT
License Clam _LICM5[et-UN
Me 4_W_q\ CIEFFECr-� -tt•=1
ARCHITECTS DECUBATION 201"1000
ro0 zZ I understand my plans.hs8 be used u public record. OVER 1 PS SQ.FT.FLOOR AREA $/SQ.FL
zz Licensed Professional C 77UCAL 11Q���^/ti ]'IT r.. D
6 ELT'I OWNER-BUILDER DECLARATION CIRCUIT/MISCI /�"j\ sail{{r.-� ' N
ZL.., Ihercbyaffirm
that am exempt from the Contractors License law the MPU o following reaxon.(Section 7015,Busines,and Professions Code:My ci ® 'tl■ P 1
P.METER OR POLE v
countywhlch requima permit toconstwd,alter,Improve,demolish,orrepalr
g anystm=mpdormlMiswancealsorequlmtheapphmntf"ou permitto POWER DEVICES
FJ O file a signed statement that he is licensed pursuant to the provisions of the VT
g
Contractor's Licerue Law(Chapter 9(commenting with Seddon 700)of DlvlMATE 0
-
�OS sion3ofthe Buslnessand PrafenloruCode)orthat heisexempitherefromand SWIMMING POOL ELEC ATION
Gthe bests for the alleged exemption. My violation of Section 7015 by any Z OUMEISSWITCFIFS '30 I
applicant fora per itwbjectetheapplicamtoa civil penalty of not morethan I\ J"" ` t �.e �G
five I,aso dollars($500). NEW RESIDENTIAL ELECTR SQ.FT, STORIES _, TYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages thele sale
fln compensation,R..doth.work.and desert. C d.: I.Th. ..metedt intended or Terme,d for
Law
sale(Sec.70K Business and Professions Code:The Contradar.License Law
S$ does net apply to an owner of property who Wilds or improves thereon and OCC.GROUP RES.UNITS
C. whoda suchwarkhimselforthraugh Neownemployen,provldedthatwch
ImprovemenbarenotlntendWorofferedforule.1(however,thebulldleg.r TOTAL: �\
_ImI(Cp1�rorv�ement is.old within oneyearofcompldlon the owner-huRderwill Tuve
FeM1 an of Em,ing that he did not build or improve for purpose of sets.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the propeuty,am exclusively contracting with licensed PERMIT ISSUANCE -2
tract..to constwd the project(Sec.7044,Business and Professions Code: 1
Contractor'.License Law don not apply to an owner of property who
Wilds or Improves, thereon and who contncts for such p(okctu,with a ALTER-DRAIN&VENT:WATER(E ) Z-
cyN�eduds)licensed persusntiothe Contractor'.License Law. RACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 7 am exempt under Sec B h P C for this reasonnljTqlnp FEES
Owner DRAINS.FLOOR,ROOF,AREA,COND.
SANITARY Y N
• Date RECEIPT M
WORKMAN COMPENSATION DECLARATION
ORATION f"T 'j,' SCI{OOL TAX Y N
E31 he. a((Ithat 1 have a certificate of consent to eel(-InwrcFIXTURES.,or I a" RFLQI'7.T
380,lab C.) S O
md(flmte.f Workers'Compewatlanlmmnceorn"kified copythemf(Sec. GAS-EA. WFEECd OUTLETS PARK FY - N
Policy a CAS EA.SYSrEM-OVER 4(EA) RECEIPT M
Com any BUILDING DIV]SION FEES copy is filed hereby
thehed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy is(fled with the tlty,inspection division, �e�.�1-1•'I
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 6 p,UQO 7 f S •� a0�
COMPENSATION INSURANCE gEWTR-SAMTARY-STORM PA.20Ff. Date Recei tii 61 �
Rhis ucti.n need ns,be complded If ted permit isfrnane hundred dotlan
($10)orinss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icedltythat In the performance of the work(arwhlch this permit biswed, —
I shall not employ any Person In any manner eo u to become subject to the WATER SYSTEM/TREATING /�?6
Worker'Compensation Lwa.f California. Data
PAID C7 V
O Z Applicant NEW BIRD EAL"B. SQFr. Date Recei tN "Z\,Q7
Z 0 NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should besubject to the Worked ns
Compeat ton provisions of the Labor TOTAL: O
M come N Code,you mu at fort hwith comply with such provislons or this permit shall be
deemed revoked.
13UILDING FE
W - CONSTRUCTION LENDING AGENCY .� SEISMIC FEE -7� �
CL Z Thereby dflrtnthat there is a emmetion lending agency for the perform- TOTAL: ELECTRICFEE
rL
7 ante of the workforwhich this pc rmitisisaued(See.3097,Civ.C.)
0 O Iendaea Nam PLUMBING FEE .W
LL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -2
OW Immilythal]have read this applicatlonand statethatlhcabove Information /
CL is cormet.]agree to comply with all cityand county ordlnanmandstatelews PERMUISSUANCE '1 �VO FEES PAI[M��./y
} 0 relating to building construction,and hereby authorize representatives of this r ✓et
Z city to enter upon the above-mentioned property for inspection Purposes. ALTER OR ADD TO MECH.
- (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei to
agaWtlbbilit4v,jud and a.Zeseswhich emyle anywayaowe AIR HANDLING UNIT(rC,I0,0XCFM) SUBTOTAL'
agalestsald Cl n ce i an tingofthl.perenit.1�7 ,,44TT�2
�419yAIR HANDLING UNIT(OVER 10,0DCFM) CONSTRUCTIONTAX
Signature.( ate'- Date If EXHALES HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant pare or handle havedous HEATING UNIT CFO 10,00 BTI]) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Iiealthand Safety Code Section 25532(a)7 FTFATING UMT(OVER 100,D0 BTI. TOTAL: a
❑ Yea No
Will theapplicant or turc building occupant use equipment or devices VENTILATION PAN(SINGLE RESIW CE DATE
which emit hazardous air coma Mrunte as defined by the Bay Area Air -
. Qu lily Management District? BOILER-COMP OTT'OR 10,0(D BTI!)
4Yea n�1No 'f a l.993
heveYes"adlhehauaouemaledab equlremnrounderChapler8.95of BO LER-COMP(OV[R10,000 BTU) % Q APR NI
the California Health&Safety Code,Sections 25505,75533 and 25534, 1
understand that if the building does not utrmntly have a tenant,that it is my NEW RESIDENTIAL.MECH. SQ.FT. �.-j�� �
responsibility to nottly the occupant of the requirements which must be met kv `p ypov�p
prior to issuance of a Cedlficate of Occupancy.
Owner or authorized agent Date ISSUED BY'
TOTAL: 3 01
OFFICE COPY
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