20479 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIItMITNO.
V Building Address: '1 S o c A- -- S v� A Lc;- R 20479
+ J
ne:r A
TTY OF CUPERTINO-BUILDING DIVISION
cemtradera Name: Lie.No; - APPLICATION I PERMIT L
S BUfLDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL# D� fi
Architect/Engineer. Lk.No: (D Ga3
QTY ELECTRIC PERMIT 'FEE BUILDING PERMIT INFO
Addreaa:
PFRABT[SSUANCE Ysll ELECI
1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION J
I
IInihthat Is.Bceneedunder pmv/aChapmmc
APPLIANCESRE51 ENTIAL Vim-l JOB DPSCRB'
ON
thSWeLierearChasm7000)of Div ftheulneesandPmteor.0da,anmy
cares 1b In full ¢ d affect. PANELS ADatCmumctcr
XV
ARCHITECTS DECLARATION 20 PS
or Z I understand my palm shag he used as public reronls O 0 SQ.IT.FLOOR AREA $/SQ.FT.
COSICNSEL TRICA
(�
Licensed professional
fnafa OWNER-BUILDER DECLARATION SPECIAL C CUIT/
7 a Iherebya(firm thatl amexempt from the Contractor's Limme,lawforthe
following reason,(&ctlon 7031.5,Roger.and Professions Code:Any dty or
f" county which requires a pemJttocorutruct,alter,Improve,d,maIE h,°rrepalr TEMP,MF, .E IN
q� anys(rudure prior to its temancq alsorequlmtheappBmn(forsuch permit to
L5 file a signed statement that,he Is Ilrensed pursuant to the provisloru of the EWER D
JE
3w Conlradors License Law(Chapter 9(commencmgwith Section 7000)ofDlvl-
O�^ simn3ofthe Buslnmsmd Pro(emiam Code)orthathebexem themfmm and SWAAfIN LELECTRIC VALUATION
Q the basis for the alleged exemption. Any violation of Section 70315 by any OU7LEISSWITCH O D r 66
applicant fora permit subjectsthe applicant to a civil penalty of net more than
m fi c undred dollars($500). NEWRESIDENII ELECTR SQ,Fr. SIO ES TYPE CONSTRUCTION
Z¢ as owner of the property,or my employees with wages as their sole
co pensation,willdothe work,andthe structure is not intended or offered for
O In(Sec.7064,Business and Professimu Code:The Contractors Llmme Law -
r3•$ does nmapplytoan owner of property who builds or improves thereon,and OCC.GROUT' RIS UNITS
who doessuchwork himseUorthreugh hisownemployees,provided thatsuch
Improvements are not Intended oroffered for sale.If,however,thebullding or TOTAL: .
Improvement bso)dwlthln oneyearofmmpletlogtheowner-buiderwlll have
the�urden of proving that he did not build or improve for purpose ofsaie.). QTY. PLUMBING PERMIT FEE
LJ b7.00D TONE APN
I,as owner of the property,em exclusively Business
ess andProwith nsensed PERMITISSUANCE
71,a Cdoneommlmctthe Law
(Sea 7064, to ness and Professions Code:
The Contractor s License Law does not apply to an owner d property who ALTER-DRAM Lk VENT-WATER(EA)
Wilds t Improves therron,and who matins for such p opm with a FEE SUMMARY
cgptlador(s)11 need nuam to the Contractor's Llrene Law. RACY FLAW PROTECT.DEVICE
u I a p u P C for lhb ra a°n
er DRAINS FLOORft REe�CD 11. $ Y I .Y N. .
Owner Date B 1 RECEBIT#
WOR COMPENSATION DCCLARATION
❑I hereby aRlrrn that I have•certiftote of cement to aeB-Insvrc,ora FIXTURES-PER TRA 0 n TAX RECEIPT It
cedifleateofWorker%Compematloalmumnworaredifledcopythemof(9ec. GAS EA.SYSTEM-1 OUTLET6✓. b' Y N
3800,lab C.)
Policy/ - I RECEIPT R
CAS EA.SYSTEM-OVER
Com any - B TIDING DIVISION FEES
Certified copy is herebyfurnished.the city
GREASE/INDU WASTEINFERCEPTOR -- - PLANCH 'KFEE
Certified copy ts flied with the dty Inspection division.
CERTIFICATE OF IXEM PFION FROM WOR KERS' GRFASEIRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM EA.300FF. DR[C RCCCI f#
(IMeio
sdn need not be completed If the permit isfor orahre
undd dollar
($100)or lees.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifylhat In the performance of the work forwhich this permit Is lisua i, —
I shall not employ any person in any munner so u to become subject to the WATER SYSTIM/TREATING
Workers'Compensation Laws o(GRfomts.Date PAID
_ plicant
Z 0 NOTICE TO APPLICANT;If,after ma king this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,FF. DRIB Remi t4f
should become sub)ed to the Workers'Compensation provlsbm of the Labor TOTAL: ;t,
N Code,you at forthwith comply with such pruvbbnsor this permitshall be,
Wdeemed revoked. BUILDING EE D
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a comtmction lending agency for the perform ELECTRIC FEE
7 Z ante oftheworkforwhlclethls permit is Issued(Ser.lIBW,CIv.C.) TOTAL:
OO lenders Nacre PLUMBING FEE
LL 1= Lenders Addmea QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW I certlfythat l have readthis appticztlonted statethatthe above information
IL is correct.I agree to comply with all city and county ordmancesand state laws PERMIT ISSUANCE FEES PAID:
>. W relating tobelldingconstruction,and hereby authorize repreentativesof(hi,
I— dcrym
to enter upon the above� entlorud property for inspection purposes. ALTER OR ADD TO MECH.
Z —Date Rece{PIN
z (We)agrcc to ssvn,Indm
enify an d keep harmless the City of Cupertino
against liabilltks,jadgments,costsandexpeneawhichmayinanywayareroe AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
agal b maxleen¢of the granting of this It. AIR HA NDLING UNIT(OVER 10,003 CIiN) CONSTRUCTION TAX
---t
Sigrar of pa oM Data IXFIAIIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will ia the defied tore uprAmobuilding occupant store hapten 9.hazardous HEATING UNIT(TO 100,000 BTU) Date Recel HI
materia as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the �s
Elealt you Safety Cody Section 75537(a)i HEATING UNIT(OVER 100,000 BTUI TOTAL:
❑ Yes No
Wiamid applicousa uNrcbuilding as defined
ndby the BayequipmantArea devices VFNDLATIONFAN(SINGLE REBID) 1591)•p_.,p �ATE
whichamidManagement air contaminants nanteasdefined by the Ray Area Air _Y L f�i
Quality Management Dkldct7 BOILER-COMP pFB'OR 1W,IX0 BTU)
YeB a"° 21990
haveread(heth&S.Ouematger,Sl i..25M,ZS33rChap(er6.95of IiOILER.COMP(OVER1(0,000BTU) - AUG
is�the Gllf0 Health h5afetyCole,Sections 7550.5,25537 and 75536. 1
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
nsponsibillty to notify the occupant of the requirements wEich most be met Cit7r Bf(!elnnFr6Dl1
priortoL uanceo(a Certificateof Occupancy. al
Owner or authmriand agent Data ISSUED BY:
TOTAL:
OFFICE COPY