20977 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification (/. /n� PEILWT NO.
Building Address: �`I I✓V Il i ✓ 20977
7
n ame: [• p
{x(91 CITY OF CUPERTINO-BUILDING DIVISION
. ce ra r'aN LIp.Ne: APPLICATION / PERMIT
BU[LDINC-ELECTRICALPLUMBING-MECMNICAL CATEGORY CONTROLM
A Ilett/Engineer.' Lie.Na:
QTY ELECTRIC PERMIT FEE, BUILDING�111 PERMIT II'LUMUNFO
Address: 7 ' O PERMITISSUANCE 12 / . .•❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that and,licensed under provisions of Chapter 9(commenc- APPLIANCESAESIDENTIAL JOB DESCRIPTION
Ingwith Sen1on7000)of DiAg.3ofthe B.Mnessand PmfesdonsCode,andmy -
license is in full force and effect PANELS
License Class Lic.M -T-GWLP,
Date Contractor 1
ARCHITECTS DECLARATION 201-1000 AMPS
MZ I understand my pbvsha6 be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
�j Licensed Professional SIGNS ELECTRICAL 11ny��`1pn1 ((^�L, '
�< OWNER-BUILDER DECLARATION SPECIALCrRCUIT/MISC . IN O V U d LE D
I„ Thereby afOrmthatlamexempHromthe Contractor License Law for the 0 V 1111
2 O following reason.(Section 76]1.5,Business and Professions Code:Any city or ® Ni
OZ TEMP.METER OR POLE INST. Qyd
F� countywhich rcqulmea permit l.covtmR,alteplmprove,demoWh,arrepair _
DWI-
an priorto its issuance,als.require.Iheapplicant forsuch permitto POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
OwI� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC er V
H 07 don of the Business and Pro(embvCods)or that he is exempt therefromand
'77 the--v.the alleged exemption. Any violation of Section 76715 by any
p<
applicant fora permit the Meant to a civil penalty of net more than OUTLETSSWITCHESEXTUI2E5
a five
Pen+ri )sets PP Pe 7'
Ove hun red as
thepro NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION'
❑I,as owner will
the property,id my employers with wages offered
dole �'�'
HO
compensation,Business and
e 6 The
st Intendedontractor or icedus Law
5 O Bale(Sec.703y Busineav and Profenlom Code:TM Contnators Llmrue Law
,$ docs not apply to an owner of property who builds or improves thereon,and CCC-CROUP RFS.UNITS
who doeasuchwork himselforthr.ugh hieawnemployee.,provided thatsuch
improvementsarenotlntendedorotferedforsaie.1(howevegthe Wildingor TOTAL: �-�.
improvement bsold withinoneyearofcomplellogtheowner-buBderwlll have '
tlA-Iurden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FIpOD 7pNE ppN
L j I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractor.License Law cion net apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wor improves thereon,and who contracts far such p(ojects with a
cc5actor(d)licensed pursuant to the Contractor's License Law. .FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reused BACK FLOW PROTECT.DEVICE
• KMAN
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y NOwner Date RECEIPT'e
WORdthat COMPENSATION DECLARATION FDCTURES PER TRAP 5C1dOOLTAX Y N_
01 M1ercby affirm that I have o certificate of consent to OP therso,or RECEIPT 0
3800,LcomficLb
Insurance ora certified copy therml�ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Iris C.)
policy p ECEDING DT M
' Coma GAS EA.SYSfEMAVER4(EA)
Y BUILDING DI VISION FC ES
wo edified copy b herebyth the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP PAID 1
COMPENSATION INSURANCE
(ThlascdIonnwd nothe completed lfthepermit bforovhundred dollars SEWER-SANITARY-STORM EA.200IT, DBIe ReceI tN
(Sl rify that In the performance ofthework forwhich this penult I.board, N_
I shall not employ any pereon in any runner n as to become subject to the WATER SYSTEM/TREATING
Workera'Compensation Law.of CaIfomla.Date PAID
Z NOTICE TO APPLICANT.If,after making this Certificate.(Exemption,you NEWRESIDENTIALPLMB. SQ.FI'. Date Remi t»
Hshould becomeeebj:ct to the Woromi''Compevatlon Provbiov.fthe Labor TOTAL:
CCN Code,you=at forthwith comply with such provisions orthls permit shall be
> deemed revoked. BUILDING W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyaffihatthere Lsaconstroctlon lending agency forthe perform ELECTRIC FEE
:3Z ane,ofthe workfer which this permit b Issued(Sec.3097,Civ.C.) TOTAL: - UO
02 Lender.Name PLUMBING FEE
LL F Lendcr'.Addma. QTY. 'MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythatl have madthls application and statethatthe above information
CL lecomct.l agree t.comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authoden representative.of this
N Z dtyto en the vo-mentloned property for inspection purposes. ALTER OR ADD TO MECH. Date RCCCI f#
_ (We a I save, con n d keep doles the City of Cupertino
:gains I II rats,cost rade sea which may in any way acoroe AIR HA NDLING UNIT aO 10,OW CPM) SUBTOTAL:
.gal d granting. i O
AIR HANDLING UNIT(OVER]D,000CIM) CONSTRUCTION TAX
Slgvture f pbcant/Cortdtd.r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant informs building occupant store or handle haysrdous HEATING UNIT(TO 100,030 BT ) Date RCCCI [N
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 0
El Yen r!No
Will theapplicanl or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IIAMLE DATE
which emit hazardous air contaminants as defined by the Bay Area A4
* Qu Illy Mavgemcnt District? BOR.ER-COMP DHPOR 1W,000 BTU)
4 Yca d No 9p9
r h,VfZia the hav oety Code,Se tions 25505,25533 and 25534.95 of BOILER-COMP(OVER IW,OW BTU) 1p9Q•
the Gi and t Health building Code,Settlors ntly h ve a t and,that i 1
understand that Bibs ntifytoccupant tithe currently merts tenancy that it met NEW RESIDENTIAL MECH. SQ.FI'
ropovibilitym of aCtheoate Of tithe mqulrcmentswhich rtwat be met fossas{pus
prior to Issuance of a Certificate of Ompanry. lM1lX W V
Owner or authorised agent Date ISSUED BY:4`
TOTAL:
OFFICE COPY