20494APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Prom Identification
nwmmg Address: 06OAK r -T
,2(7 SPgntS�
PERMIT NO.
20494
era one.
A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
` l
e tracto . ante Lie. o:
Osri �Ii3�
m
UMH
CONTROL8
Archil gineer. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dtlrrn that l am Roensed under provisions of Chapter 9(rommenc
Ingwlth Se ion7000)of DiWslan3ofthe BuslnmandPmfmionsCodgandmy
license is in full II force and dfeR. s�// �
License Chss Lk.N�T
Date Contractor
APPLIANCESRE9 L
JOB DESC ON
,
1`t^i�iPp1`,-•: 1Msl`.t`Ir3'-C`tr?
PANELS i
201-1W0 PS
ARCHITECTS DEC RATION
y P e be as public.mds.
OVER 1
SQ. FT, FLOOR AREA
S/SQ. FL.
SIGNSEL AL
LI sed Poefftioner
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt fromthe Contractor's License Law for the
SPECIAL T/
following reason. (Seaton 7031.5, Business and Professions Code: Any city or
county which requtons a permit to construct, alter, Improve, demolish. or repair
TEMP. O INSf.
any structure prior to its lssuanen, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the prov= of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) o(Divi-
xkm3oftheBusinmand Profe.bns Cde)orthathebexemptthemfmmand
the bas's for the alleged exemption. Any Wolatkm M SccHon 7m IS by any
applicant fora permit subjects the applicant to a civil penalty of not more than
EVI
N L T
VALUATION
O EISSWITCIiFS FS
W RESIDENTIAL ELECTR SQ.FI.
live hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSTRUCTION
compensation, wllldothe work, and the structure is not Intended or offered for
sale (Sec. 7Wk Business and Professions Code: The Connaaoes License Law
TOTAL:
does not apply to an owner of property who Wilds or improves thereon,and
who does such work himself w through his own employee, provided that such
improvements are not intended orotfered for sale. If, however, lhebuilding or
Improvement bsold within one yearofcompletion, the owner-bullderwlil have
OCC.GROUI'
RFS. UNITS
t Men of proving that he did not Wild or improve for purpose of sale.).
Lj L as owner of the property, am exclusively mntraaing with Licensed
contractors to cosutroa the project (Sm 7W4, Business and ProfessionsCode:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
OJT -
p1,OpDzONe
TpN
The Contractors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such In ods with a
dtt dor(s) licensed pursuant to the Contractor's License Law.
I_J 1 am exempt under Sec. B k P C for this reason
pLTFR.DRAIN k VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby afllrm that I have a certificate ofconsent to self -Insure, or a
certificate of Workera Comper Batton Insurance ora certified copythermf (Sec.
380, Iab C.)
Policy N
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
RECEIPFN
FD T UR6S PER TRAP
SOiOOL TAX Y N
RECEIPT N
GAS EA. SYSTEM -1 INCA OUILEIS
—
PARK FEE V N
RMO Pp N
Com any
[�Certifid copy b bed with t fished.
I'njtc�rtified copy b (fled with the city inspection division.
GAS EA. SYSTEM-OVER6(EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDWCDI VISION FEES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ITMxW
sctlon need not completed lithe permit b (or ane hundred dollars
PAID
Date Recd t#
SEWERSANITARYSIDRM EA 200FT
SlIO)orf
Icertityththa in the performance olthc work (orwhkh this Permit bhomed,
1 shall na employ any person In any manner so es to beco sub' to the
Workers Cora/g/, tthnn La b. gate
Applicant
11 WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Reeei t#
WATER SYSTEM/TREATING
- _ .T
NOTICETO'APPLICAN 1: ILatter ngt is Certificate of Exemption, you
should become subjed to the Workers' Comperuation provisions of the Labor
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
NEWRESIDENTIALPLMB. — SQS
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
Ihercbyafifirceorkfo whichat t Lsaermitualon lending agency for the perform
once of the work for which this permit b issued (Sec. 3097, Civ. CJ
1`nder's N.me I
Lenderapaareas
Icerifythatihave readthlsapplicathe dkdk mthetheaboveloformadon
TOTAL:
SEISMIC FEE
ELECTRIC FEE Z x
QTY. MECHANICAL PERM IT FEE
PLUMBING FEE
MECHANICAL FEE
Is mrrea. I agree to comply with all city and county ordinances and state laws
relating to building construction, end hereby authorize representatives of this
city to enter upon the above-mentioned property for Wpedon purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
.,.Inst liabilities, judgments, costs and expenses which may In anywayacaue,
against said City In cont a moft a graining of this permit.
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (T010,000 CFM)
FEE —PAID:
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
LL//(/ may/
—/
S� mW�11mo Applicant�e r D`
HAZA kDOUS MATERIALS DI SCLOS URE
FXFIAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,ODO BTU)
Will the a ppVant or future Wilding occupant store or handle haeardous
.teri.l as defined by the Cupertino M.Mdpal Code, Chapter 9.12, and the
Hcalthand Safety Cde 25532(.)7
❑ Yes LOIN.
Date
HEATING UNIT (OVER 100,000 BTU)
TOTAL•
Will the applicant or future building occupant use equipment or devices
which emrd
it haze ous air ecoUndoanb as de0ned by the Bay Area Air
Qulity M.rugemcnt Distrl
Yeao
VENDLATION PAN SINGLE RESID)
ISSUANCE DATE
BOILFR-COMP Otey OR 100,0(U BTU)
4h.veredthehaza ous materials requirements under Chapter 6.95 of
.the Ceiifomia Health h Safety Code, Sections 25505, 25533 and 25534. I
understandlhat lithe building does not currently have amnanpthat it Lsmy
responsibility to notify the occupant ed the requirements which must be met
C�q►p'
BOILER-COMP(OVER 100,000 BT U)
NEW RESIDENTIAL MECH. $Q,FI',
prior to issuancea rtilkptrcupanry.
�(
0 199
ISSUED Y:
Owner or authorized agentt Date
TOTAL:
OFFICE COPY w—jum