20606APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
building Project Identification
Bonding Address:
/ y,oro f ! /iz � ,ate �n10
PERMIT NO.
20606
i -Avner ante: one.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBING-MFGFiAMCAL
A A A
(�
Co radorsNarrc: Lia Ne,
CATEGORY
CONTROL a
1 Architect/Engineer. Lie. No:
QTY ELECTRICPERMFT FEE
BUILDING PERMIT INFO
Address
PERMETISSUANCE (Ja
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commcoc
ingwith5 ion70D0)ofDMsian3ofthe Businessand PmfessionsC c,andmy
license la In fug force and effect.
License Claw Lic.a
Date Contractor
ARCHITECPS DECLARATION
I underatand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
m
I hereby affirthat I am exempt from the Contractor's License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
coontywhichrequiresapert ttoronstmC,alter,Improve,de=n h,orrepair
anystmmmpdortoitsiwuance,aL requireatheappgrant(wsuchpem tto
file a signed statement that he la licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7DOO) of Divi-
sion3 of the Businessand ProfessionsCode)orthat he is exempt there(romand
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 ore than
five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as their sole
compensation, wgl do the work and the structure is caw Intended or offered for
sale (Sec. 7034, Business and Professions Code: The CestraRors License law
does not apply to an owner of property, who builds or improves therroq and
who does such work himself or through hisownempleyees, provided that such
improvementsarerout Intendedoroffer forwle. ILhowever,thebuildingor
improvement Tssold wlthinoneyecurofcompldioM1theowner-builderwill have
t en of proving that he did not bund or improve for purpose ofsals.).
L as net of the property, am exclusively contracting with licensed
In into coentrod the project (Sec.7034, Businessand Professions Cede:
Contractor's License law does not apply to an owner of property who
Itch or Improves thereon, and who contract for such p(ojecs with a
o7alIactw(s) licensed pursuant to the Conmadoes License Law.
LJI am exempt under Sec. B k P,C for this on
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRIPTION
y i —a..
L Pi,-`+.
201-10DOAMI'S
OVER IODO"I'S
SQ. FT. FLOOR ARTA
S/SQ.FT.
SIGNS ELECTRICAL
,�.syy�am
SPECIALCBtCU1T/M15C x W
TL�yfP. METER ORPOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLE'ISSWITCIiESEXTURES
NEW RESIDENTIAL ELECTR
W ES
TYPE CON'SIRIX:TION'
OCC.GROUP
RF9.UNUS
TOTAL;
QTY, PLUMBING PERMIT FEE
I'FRM1T L'STIANCE
ALTER -DRAIN &VENT- WATER (EN
)ZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FEES
Owner Date
DRAINS FI -DDR ROOF, ARLA,NND.
FIXTURESS PER TRAP
SANITARY Y N_
RECEPT a
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Worker Compensation Insurance ars certified copy thereof (Sec.
38U, lab CJ
Pdicy p
SCHOOL TA% Y N_
RECEIPT Y
GAS EA. SYSTEM -]INCA OUTLETS
PARK FEE Y N
RECEIPT' M
Com
om
Cny
copy, V hereby furnished.
E] Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE
(Thissectionneed not becomple if lfthe permit b(wons hundreddollan
(SIW)orlewJ
that o any person In ny mannerhc wf.as to b this a sibjecrmit I. itwed,
I
I shall caw employ any person In any manner m as to become ¢object to the
Wwker Compensation Iowa of CaB(ornla. Date
Applicant
NOTICE TO APPLICANT: U, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation prevolov of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING ACGiCY
Ihercm
bya(nrtlutthere Lvaconstmdion lending agency for the perform,
ance of the work for which this permit Is Issued (Sec. 3097, Civ. Q
Lender's Name
Address
Icertifythatlhave readthisappliwtionand ttethzttheaboveinformatlon
Iscorted. I dgmete, comply wlthall cityind county ordinance and state laws
Mating tobullding ronsttudion, and hereby authorize representaUvea of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an it keep harmless the City of Cupertino
against liabilities,judgments, costsand expenses which may in anywayaceme,
against old City in consequence of the granting of this permit.
CAS FA.SYSTEM-OVERd(FA)
CREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DI VISION FEES'
PLANCHECK FEE
PAID
Date Recei tit
GREASE TRAP
SEWER -SANITARY -STORM IIA. 200FT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N—
PAID
Date Recei tIt
WATER SY9CF1d/TREATING
NEW RESIDENTIAL PLMB.__SQFT.
TOTAL:
BUILDINGE
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTER OR ADDTO MECH.
AIR HANDLING UNIT ITO I,D00 CFM)
Date Reeeiptif
SUBTOTAL:
AIR HANDLING UNIT (OVER jQ0a0CFM)
CONSTRUCTION TAX
IB"a f P " ontra Tote
HAZARDOUS MATERIALS DISCLOSURE
eappllcard orfuturebuilding—pant score or handle hazardous
ma al as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I lealth and SaletyCade Section 75532(x)7
1`7Yes r] No
nt usedby the BayequipmentArea devices
Willanti appliwntorfmorebuilding as defined
which emit havrdous air ronbminanb ea defined by the Bay Arca Air
Quality Management District?
Yn gnus
havoread Health SalesCeile,btions 25505, 25SderChapter 25534..95 of
the Califomla IIeaIM k Safety Code, Sections 25505, 25533 and 25533. I
understand that if the building does not currently have a tenant. that it is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
D(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date RCCej tis
HEATING UNIT (OVER 10,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
)
JUN
11 1
JVl'7 ^ IyJ�
_ I)
/Zsry'ri EnrP>(i
ISSUED Bis In
BOILER -COMP 0HPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.F7.
Owneror authorized agent Date
TOTAL:
OFFICE COPY