20807APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification - -
Building Addren:
PlikbtlT NO.
20807
�040C -1 sane.
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION I PERMIT
BUILDI NGELECTRICA4I'LUMBINC- MLCHAMCAL
A A
Crxeraatar'aNNaame; Lie. No
^" "�
CATEGORY
CONTROL M
Architect /Englncer. Lie. No:
QYY`
ELECTRIC PERMIT '
FEE
BUILDING PERMIT INFO '
Address: 3 yy s - ..�
PFRMITISSUANCE
v-S/
❑ •j�j ❑ ❑
LQ
LICENSED CONTRACTOR'S DECLARATION
-
I hereby affirm that l am licensed under provisions of Cha peer 9(rommenc-
Ing with Section 7000)of DiAgm, 3ofthe Bu arnsa.ed ProtessionaCod, and my
license is in lull /JPd fifes.
License Chat �= '� Lle a J�y�O 9
Date Contractor
APPLIANCES.RFIDENTIAL
JOB DFSCRB'TION
f
PANELS
Y01 -1000 AMTS
ARCHITECTS DECLARATION
I understand my phu shall be used u pulsHe records.
OVER 1000 PS
SQ. FT. FLOOR AREA
f/S0.. FT.
SIGNS ELFG
Licensed Pr femloml
OWNER - BUILDER DECLARATION
I herebyaffirse that I am exempt from the Contractors License Law for the
SPECIALCIRC
POLEI
p0 S
lollowingma n.(5ed1on70315,Buslnenand Pro /anions Code:Anydtyor
county which requi a ra permit to construct, alter, Improve, derrolbh,oreepalr
anystructure pdorta its Issuance, also requlrestheappliernt forsuch pe Thin
file a signed statement that he b licensed pursuant to the provleloim of the
Contradors License law (Chapter 9 (commencing with Section 7000) of Divl-
sion3oftheBuslnenandPm iomCode )orthathebewmptthemfmmand
the baetr 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
IWL E4XC
VALUATION
't
OUTLE TCHFSH%TURES ,'�t
1
NEWRESIDENTIAL ELECTR .PT.
flue 1, as owner ofth pcxe
I, as owner o! the or my employeu with wages a there sole
STORIES
TYPE CONSTRUCTION
compensation, a worky,
work and
knot Intended or offered for will
(Sec.7 Business
sale (Sec. 7014, Bualnen and Professions Code: The Contractors License law
ions Code:
QTY,
TOTAL:
PLUMBING PERMIT
pp yP �gUANCE
Z 7(
aimprove
FEE
does not apply to an owner of property who bullda or improves thereon, and
who doeasuch work himself orthmugh his own employees, providedthalsuch
Improvements arc net intended oroffemd for sale. U however,thebuildingm
menthBaldwithinomyearofcomplet mtheowner- butiderwlll have
ilrr*,den of proving that he did not build or improve for purpose of sale.).
Lf L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See 7076, Bualnen and Profenlons Code:
OCC .GROUP
TZIS , UNITS
FLOODZANE
APN
,
TM Contractors License law does net apply to an owner of property who
ibuilds or improves thereon, and who contracts for such projects with a
➢t(actor(s) licensed pursuant to the Contractor's License Law.
J I am exempt under See. B & P C for this reason
ALTER -DRAIN & VENT. WATER (En)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS. FLOOR, RODP, AREA, COND.
FIXNRES PER TRAP
SANITARY Y N_
RECEIPT N
Owner - Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self - insure, or a
cenlfiate ofWarkere Compensation Insurance ma certified copy thereof (Sec.
3800, Lab C.)
SC7300L TAX Y N
RECEIPT — NM
GAS EA.
PARKFRE Y_ N_
P.11ry Y
RECEIPT N
Coco any
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION PETS
MCertlfied copy is hereby dwth the city
�CcrtlOed copy h tiled with the city Inspection division.
GREASE /INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thos cession need net be complded tithe permit h !Drone hundred dollars
(8100)arlen.)
I thatln the
I shall not employ any person In any manner so u m become subject to the
any person in so as to bco eemnith6othe
Workcrs'Compensation Gwa of G ll(omla. Date
NOTICE
NOTICE TO APPLICANT: If, after making this Ctio prhis Exemption, you
Code, you must forthwith comply with such provisions orthh permit shall be
Code, ou=a aforth mthe Work en' Compewtlonpmvhis permit s Labbe
Beamed revoked.
PAID
jute Recd t#
SEWERSANITARYSIORM EA. WOFT.
WATER HEATER W /VENT /E.ECTR
ENERGY FEE Y N-
—
PAID
Date Recei t#
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB. _SQ3T.
IOTA .
N
TOTAL:
SEISMIC FEE
ELECTRIC FEE
tI
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for the perform
ance, of the work for which this permit h issued (Sec. 3097, C1v. C.)
Lender's Name
Lender's Address
I cekilythat I have read this appllatlonand statethat theabove Information
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PGES PAID:
incorrect. I agraeto comply with a0 cityand county ordinances and pate laws
PERMI77SSUANCE
relating to building coutmcibn, and hereby urthoolu representatives of this
city to enter upon the above,mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, jsdgments, exatsand expenses which may In anywayacems
against said City In consequence of the granting of this permit.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CPM)
Date RCCei t#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sigvtumof Applicant /Contractor Data
EXHAUST HOOD(W /DUCD
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUMT(TO10D,000BTU)
Willtheappllantorf arumbullding.pantstoreorhandleba rdous
outedal as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Healthand Safety Code Sedlon25532(a)7
F� Ym No
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
s (0
VPNDLATTON PAN(SINGLE RASID)
r.�
ISSI)pA ATE
!l
C•��i+ �w .7 `C
i ^ ✓V .
Illthe haeardntor sureminats., drred by the Bay Area devices
which emit haaardous nor contamiranb ae defned by the Bay Area Alr
Qua llty Management Dhkkt7
4 Yea No
have read the hazar ous materials requirements under Chapter 6.95 of
the Califomla liezlth & Safety Cod, Sections 25505, 25533 and 25537. I
BOILER -COMP OFfP OR 100,0(10 BTU)
BOILER- OOMP(OVEt 100,000 BTU)
NEWRESIDENTIALMECH. SQ.FT.
understand that if the building does not currently have a tenant, that it fir my
responsibility to notify the occupant of the requirements which at be met
'
City
prior to issuance ofd Certiticate o(Ompanry.
of (`l Ir,P
a rhno
, US>
ISSUED BYI- Si:��t1O!a�rr^►Y -C
Owner or authorleed agent Date
TOTAL:
OFFICE COPY