20543APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Ada ^ 17 N S Olt]
20543
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTWCA PLUMBING-MECIIAMCAL
APPUCATION A
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Conte rs Na 1 ply( //� Lie No-
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Archilen i;jSer LIB No:
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CATEGORY
CONTROL p
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ELECTRICPERMIT - FEE
BUILDING PERMIT INFO
Address 7 S{ N O 5, �. (/J�.
BLDG ELDCJ PLUMB MLLH
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc
Section7000)of Divislo'3 ofthe Bu 1mesand ProfeaslorsCode, and my
Iiunse is In lull r and dfec �qr fan (j,
License Cho cal LIC.N 7/�lrr
Date Contractor
APPLIANCES -RESIDENTIAL
JOB DESCRIPTIONIngwith r,
11 tea.
PANELS
201 -IOW AMP"'
ARCHITECT'S DECLARATION
I understand my plamshallbe used es public records.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
5/SQ.FT.
SIGNS ELECTRICAL
Limned Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt fromthe Contractors License Law for the
'
TEMP. METER OR POLE INST.
following reason.(Sectlon7MIZ, Buslosciand Professions Code: Any city or
ewntywhich mqu res a permit to mmtmd, alter, Impmve, demolbh,orrepair
any etrodure prtorto Its bsuance,aiw requircatheapplican[fuauch permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and PnefeolomCode) or that he lit exempt therefromand
POWER DEVICES
'
SWIMMING POOL ELECTRIC
VALUAPQN
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not morethan
OU7LE.ISSWI.fCIIF_SHX1'URFS
09:
�/ O0Q'--
NEW RESIDENTIAL ELEC7R SQ'Fr'
five hundred dollars (SM.
❑ 1, as owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation, will d o the work and the stmMm is not Intended or offend for
.Is (Sec 7044, Business and Profession, Code: The Contractors License law
does net apply to an owner of property who builds or Improves thereon, and
who does such work himself orthrough his own employees, provided that such
OCC.CROUP
RES. UNITS
Improvements are not Intended muttered forsals. If, however, thebulldleg or
improvementiesoldwithln oneyearofcompldbMtheowner-builderwlll have
TOTAL:
ttetvrden of proving that he aid not build or improve for purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 70K Buslneas and Professions Code:
QTY. PLUMBINCTERMIT FEE
Pp pr ISSl1ANCE
FLOODZDNE
APN
The Contractor's License Law does net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptp*u with a
cgpVactor(s) licensed pursuant to the Contractor's License Law.
IJ I am exempt under Sec. B k P C for this reason
ALTER -DRAIN kVENT-WATER (EA)
BACK FLOW PROTECT. DEI7CE
FEE SUMMARY
OUTSIDE rrrq
DRAINS FLOOR ROOF, AREA, COND.
PER TRAP
SANITARY Y N
RECEIPT #
Owner Date
WORKMAN COM PENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell -insure, lnsure, ora
C31
certificate of Workers'Compemation Imumnm ora unified copythersof(Sec.
3800, lab C.)
SCHOOLTAX YN
_
RECEII'f N
GAS EA. SYSTEM-1INCA OUTLETS
PARK ETF.- Y N
PolCoins N
RECEIPT#
Y
GAS EA. SYSTEM -OVER 4(FA)
BUILDING DIVISION FEES
Certified copy is hercbyth the
he city
R)Certified mpybfiled with th<tlty Inspection division,
Yx CERTIFICATE OF I7(EMPSION FROM WORKERS'
COMPENSATION INSURANCE
(This session nets not W completed if the permit b T'u'ne hundred dollars
(StW)orlsss.)
I cent that o any personhe I anye of m neerwork for ss to b become rmit isbo the
I shall not employ any person in any manner w m to become subject to the
Workers* Compensation laws of California.ATER
. Date
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCI-IE KFEE
PAID�7O
Date Recei t#
GREASE TRAP
SEWER-SANITARY-S(ORM FA 200Fr
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workeri Compemallon provision of the Labor
Date RCcel [#
NEW RESIDENTIAL IPLMB. SQ.IT.
TOTAL:. U
Code, you must forthwith comply with such provisions or or this permit shall be
deemed revoked.
BUILDING "E
.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaf rm that there b a mmtruction lendingagency forthe perform.
once of the work for which this permit is Word (See. 3097, Civ. C.)
TOTAL:
ELECTRIC FEE
Lander. Name
Lenders Addrsu
I cenlrythall have mad this application and nate that the above Information
bcormet. I agree to comply with all city and county ordinance and state laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID: '
relating to W Ilding construction, and hereby authorize representatives of thio
city to enter upon the aWvnmcntloned property for inspection purposes.
(We) apegy , den y an d keep harts the City of Cupertino
against ics,)ode est eased exp sea I may In any accrue
agai Bald City In me n M o spermit.
ALTER OR ADD TO MECH,
Date RecCi f#
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER lo,WOCFM)
CONSTRUCTION TAX
pucant/Contractor PVCZ 19, tc
EXHAUSTHOOD(W/DUCD
CONSTRUHION TAX PAID:
HAZARDOUS M :RIALS DISCLOSURE
1ocupant
HEATING UNIT (TO 100,000 BTU)) -
Will th appllc.'rd., uturc Wi store or handle hazardous
material as defined by the Cupen ' Municipal Code, Chapter 9.17, and the
Date RCCCI [#
HEATING UNIT (OVER 100,100 HIM
TOTAL:
I lealth and Safety Code Section 25532(a)?
❑ Yes II No
VENTILATION FAN (SINGLE RESID)
S DATE
JUry t y
JU
Will the applicant or forties building omupant use equipment or devices
which emit harsrdous air contaminants as defined by the Bay Area Air
Qu a lily Management District?
Yn nNo
havereadthebauriousmatenalsrequlmm ntsunderChapter6.95of
BOILER -COMP (311P OR 100,DM BTU)
BOILER-COMP(OVER100,000BIU)
the California Health k Safety Code, Sections 25505,25S33 and 25534. I
understand that if the building does not currently have a tenant, that it is my
/s
City B�Cupef`:ap
NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requircoents which must be mM
4N
prior to Issuance of a Certificate of Occupancy.
IfiSUED lly s�UJ`G/II Ai
Owner or authorized agent Date
TOTAL:
OFFICE COPY