20929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT.PEN ONLY
Building Project Identification PERMIT NO.
eulrate Address: �pi 20929
YY�/ ✓
nems ante. one: _ A-
w - CITY OF CUPERTINO-BUILDING DIVISION �1
ractar.Name: APPLICATION /PERMIT
. ArcMteci/Engineer. Llc.No: BU[LDING-ELECTRICAL-PLUMBING-MECI-LAMCAL CATEGORY CONT9011fP'�Q,^
QTY .: BLECTRIC PERMIT. ':,;FEir, BUILDING'PERMIT INFO'
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter 9(commene-. APPLIANCES RESIDENTIAL JOB DESCRIPTION'ngwlth Section 70W)off)ivlslon3ofthe BusinemandPmfessionsCode,and my
I icense le In effect. PANELS
LiC,=C Ic.p �C)
Datontractor la rJ
ARCHITECT RA a.L�G��jq�'((JJ 201-1000 AMPS
NZ I understand my plans shall he used as public records./�(���Y/•R� a OVER I000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ecy kvj Licensed Professional J's^a� SIGNS ELEC]T.ICAL
G� n N OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC NA L E D ' 'A'
1herebyafflmrthat lam exempt form the Contractors License Law for the
2`..,o-H� following reason.(Section 70315,Business and Professions Code:Any city or
mT E R
FZ u9 countywhich requlresaperMttororistruq alter,impmve,demolish,orrepair TEMP.METER OR POLE INST.
lo ,
d anystructure prrtoits Issuance,also requlrestheappllcant forsucE perenitto
file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divt- SWIMMING POOL ELECTRIC TE I - -
�0� sion3ofthe Businessand Prof ioisCode)orthathelaexempttherefromand _ UATTOIsj
Gthe basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHESFDCITRtES J
applicant fora permit subjects the applicant to a civil penalty of nat more than
O five hundred dollam(¢5W).
F1 I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELLCTR SQ,Fr. STORIES TYPE CONSTRUCTION
compensation,wBldothe work andthe structure is not ntended or offered for
OIs(Sec.7094 Boston..and Professions Code:The Contractors License Law
3 does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
suchwork himself or through his own employees,provided that such ,
Improvements are not intended oroffered forage.If,however,the building or TOTAL;
r Improvement issold withinoneyearofcompletion,theowner-builderwill have I I I . `
t"men of proving that he did not build or Improve for purpose ofsa4J. QTY, FEE .' FLOOD ZONE APN
u L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
contractors toc ustroctthe ported(Sec.7044,Business and Professions Code:
The Contractor's Limnse Law does not apply to an owner of property who
Weds or Impraves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
co,t Ltt[[actor(a)limmed pursuant to the Contractor's License Law. ' BACK FLOW PROTECT.DEVICE ''PEB SUMMARY -
LJ I am exempt under Sec. B &P C for this reason
OUTSIDE FEES
Owner Date DRAINS)FLOOR,ROGF,AREA,COND. SANITARY Y N
• RECEIPT p
WORIGIANCOMPENSATIONDECLARATION� FIXTfTRES PER,IRATs SCITOOL TAX Y_ N{hereby affirm that 1 have a certiacate of consent to self-insure,ora
�rif4Cczeeo(Worker%ComO !
.
PLANCHECKRECE
P'T
I
38W,LabCW 740
_-Lin GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Policryap nY —Tt� GAS EA.SYSTEh-0VER6(FA) RECEIlTM
CuC . FEE BUILDING DIVISION FEES
riffled copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR
''7 sir C�J(f/ ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID L_� `� 1 'A(l,ya
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200£7, Date Remi g •TJ ,"ja
(This section need not be completed[(the permit V(or ane hundred dollars
($IOo)orlyth) WATER HEATERW/VENT/ELECTA ENERGY FEE Y N
Icertifythatothe performanceof thework so as to become
permit Is issued, I (
I shall not employ any person in any manner eo as to berme subject to the WATER SYSTEM/TREATING
Worlicant mpensatlan Laws of California.Date PAID
O Z Applicant `
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFI. Dale RC 1 tp
should become subject to the Workers'Componegion provisions of the Labor TO AL:
N Code,you most forthwith comply with such provisions or this permit shall be
> deemed revoked. _ BUIL NG FE
aCONSTRUCTION LENDING AGENCY SETS
I hereby affirm that there le a construction lending agency for the perform- ELE
0 ance of the work for which this permit is Issued(Sec.3097,Civ.C) TOTAL
O Lenders Name PLU N FEE
IL F LendersAdareea QTY. MEC$ANICAC'IERMIT FEE, MECHA E
O W Icertifythatlhawere.dthsapphrationandrtatethmineabovelnformatlon 11rr�� �vf
is correct.I agreeto comply with all cilyand county ordlnanres and state laws PERMIT ISSUANCE
} C relatingta building construction,and hereby authorize representatives afthls
F N city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino ate Reeel to
O against liabilities,Judgments,costa and expenses which may inanywayaecrue AIRHANDLINGUNIT(TOI0,0D0CFM) CV SUBTOT
against said City In conexryence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slgrawne.f Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
"
Will the applicant orfutum building occupant store or handle hacamots HEATING UNIT(TO 100,000 BTI)
material as defined by the Cupertino Municipal Chapter 9.1 Date Rec 1 tN'
y pe Pa p[ 2,and the
IlSafety Code Section 2S532(a)i [SEATING UNIT 100,000 BTU) TO L
71yea :
Yea M No
Will the haxanantorfstone building as defined
ndby the Bay Area devims VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emitnagement air contaminants as defined by the Bay Area Air �®
Quality Management District?. BOILER-COMP(3I-POR 100,0(q BTU)
4 Yes n No
havernia earthhe a o�mode,Sections
e mqufmmnts 25505,25533
55 5,2553 and255346.95 of BOILER-COMP(OVER l00,fN)ll BTU)
the Californiaat fish &Sad Code,Sen lona25ly have533and,that 1 UL, 1
understand that notify
the occupant note requir have.tenant that it Is out NEW RE9DEN77ALMECH. SQ.Ff.
respprior to issuancelity to oft Certiic to of Ocf party.requirements which most 6e out
prior to issuance oft Certlficite of Occupanry.
Owner or authorized agent -Date ISSUGDB `� '
TOTAL:
OFFICE COPY