20795APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
tlulldln Pro act Identification
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20795
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CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION I PERMIT
BUILDING- ELECTRICAGPLUMBINC- MECIIAMCAL
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Comrednr'•�M/Tame: a ur. o:-
l s!•S VAC�t �K PN �(
CATEGORY
CONTROL
Archked /Engineer. f LTC. Nm:
QTY
ELECTRICPERMIT
FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑ ❑ El
CONTRACTOR'S DECLARATION
Ihthb i. @000)ofam Bcen3aftheerprovlandPrtChionsC owmmenc-
InenseI eHon7000)ofd vlslon3a(thegusineasand ProfessloneCode andm
license b In fur t'Ijand offs,. n
License Clam LleM 2(166, S` %
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contradorm License Law for the
following reason. (Section 7031.5, Buslneas and Profession. Code: Any city or
county which requires a perre t to consteact, alter, Improve, demollsh, or repair
anystrudure priorto its bsuance,also rcquireatheappllcan t forsuch permltto
file a signed statement that he Is licensed pursuant to the provblom of the
Contradorb License Law (Chapter 9 (commencing with Section 7000) of Did.
Non3ofthe Buelnewand Prof esslonsCode )orthat hebexempttherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred 1, aso dollars %W,
I, as owner of is, properly, or my employees with wages as there dole
compensation, w .don., and Professions ions Code: The C Intended or coffered for
.to (Sec. apply to ainowner Profession hobuiThe or improves License Gw
daws who apply work lw property rough whob empoy.,prothercaryand
who doessuch workhimael( rrthtwgh his ownemployee ., provided that or
Improvements am not intended oroffered for sale. If, howevcp thebullding or
improvement isaald within one yearofcompldlon, the owner- budderwlll have
th rden of proving that he did not build or improve for purpose ofeale.).
�I, as owner of the property, am exclusively contracting with licensed
contractors to construct the pmject (Sec. 70" Business and Professions Code:
The Contractor'. License law does not apply to an owner of property who
builds or Improve thermos, and who contracts for much piojects with a
wAacmKs)Insured pursuant to the Contradoes Mcome Law.
I_l l am exempt under Sea B & P C for this mason
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
j
M..
PANELS
UP TO 200 AMPS
211- I000AMPS
OVERIOWAMPS
SQ. FT. FLOOR AREA
$ /SQ. FT.
SIGNS ELECTRICAL
SPECIAL CIRCUIT /MISC
TAP, METER ORPOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCFiESFl%T'URFS
VALUATION
NEW RESIDENTIAL ELECTR SQAT,
STORIES
TYPEGONSIBUCTION
QTY,
—
TOTAL:
PLUMBING PERMIT
FEE
OCC .GROUP
RES, UNITS
'
PERbIITISSUANCE
ALTER - DRAIN & VEM -WATER (EA)
lZ 0
FLOOD TONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE ITce
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
DD
SANITARY Y_ N
RECEIPT Is
Owner Date
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that I have • certl0ntc of conmom to .elf - Insure, or •
cemNcate o(Worken'Comperualmn Insurenceora certi(kd copythemof (Sec.
3800, lab CJ
Pocky
SCIdOOL TAX Y N_
RECEIPT N
GAS EA.SY53'Ehf -I INC.40[fILE15
PARK FEE Y N
RECEIPT a
CAS FA. SYSTEM -OVER 6 (EA)
Coss y
B U ILDING DI VI SION FE FS
CCeertified copy b hedwith the cif.
Certified copy b (lied with the city W pectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed lithe permit b forarie hundred dollars
($100) or rem')
I mortify that In the performance of the work for which this Parma is Issued,
I shall not employ any person In any manner so as to become subject to the
Workers' Compensation Laws of California. Date
Applicant
NOlicant AI'PLICANT:IL aker making fhb Certificate o(Exemptlan, you
should become subject to the Workeri CompewHon provisions of the Labor
Code, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hembya(flrmthat there is a construction lending agency for the perform-
ance of the work for which this permit b issued (Sec. 3097, Civ. C.)
Laeaer' Adam
I certlfythatl have read thisappllcatlonand statethatthe above Information
rr
bcoect. lagrcem comply with allcityand wuntyordNanonand ciete law.
relating to building construction, and hereby authorize representatives of this
city to enter upon the above�mentloned property for inspection purposes.
CWe) agree to move, Indemnify an d keep harmless the City of Cu part [no
against liabilities, judgments, wets and expenses which may In any way acewe
xgai Id City to ence of the granting of this Fermi
� �� L
CREASE /INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Ream ti♦
GREASE TRAP
SEWER - SANITARY -STORM EA. XIOFT.
-
WATER HEATER W /VEN' ECTR
, t) 1!
ENERGY FEE Y N —
'
PAID
Date Reoei tN
WATER SYSNH /TREATING
NEWRESIDE- MALPLMB. SOFT.
TOTAL:
BUILDING
TOTAL:
-
SEISMIC FEE
ELECTRIC FEE
QTY.
MECHANICAL PERMIT
F'GE
PLUMBING FEE
. 0
MECHANICAL FEE
PERMIT ISSUANCE
FEESPAID:
ALTER OR ADD TO MECH.
Date Receiptil
AIR HANDLING UNIT GO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER l0,000CFM)
CONSTRUCTION TAX
Sig ture of Applicant/Contractor Darn
HA74RDOITSMATERIQSDISCMSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 91Z and the
Health and SafetyCodeSecdon75537 (a)7
M Yes M No
Willthe applicant or futurebullding occupant useequlpment ordevices
which emit hazardous air contaminants as defined by the Day Area Air
Qu IBy Marugement District?
4 Yes 9 No
haveread the hazar o.. materials requirement sun der Chspter 6.95 of
the CelifomW Health &Safety Code, Sodium 25505,75533 and 75534, I
understand that lithe building does not currently have a tenant, that It is my
respansibllity, to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
EXHAUS "rHOOD(W /DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 10),000 BTU)
-
Date Recejpttl
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
-DI
VENTILATIONFAN(SINGLE RESID)
ISSUANCE DATE
PAJD
4' a IA t+.
..
City, of. Cunertjrto
ISSUED
BOILER- COMP (311POR 100,DM BTU)
BOILER- COMP (OVE4100,000 BTU)
MEWRMDENTIALMIECH. SQ.FT
Ownerorauthonwd agent Data
TOTAL:
OFFICE COPY'