20747APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Building Address:w�` !�
7^ CLaL �
NO.
20747
�re arre:� erne:
.(-do'sJ'
CITY OF CUPERTINO BUILDING DIVISION
APPLICATION/PERMIT
BOLDINGELECTRICAI,kUMBING-MF,CHAMCAL
p
^
1 l "tel
cat nnraname:w, LeNa:
CATEGORY
CONTROL M
Architect/Engineer. Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addmaa
❑ 1:1 EE
PFRMITISSUANCE ULOP
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment,
Ingwlth Section 7000)of Division 3ofthe BusinensanciPrefessionsCods, and my
license Io in (u orae and effect.
Llanse ClaeaLyo C.cr, !
Data �/D � Cr, Contractor
T -rte l�ARCHITECI'S ECLARATION
I understand my plana shall be used as public remrdo.
Licaurd Professional
DECLARATION
OWam exempt
I herebyl0
armthat I am exempt from the Contractors License Law for the
following .... election 7031 S, Business a rad Professions Code: Any city or
cauntywhlchrequlresapermitrommu Malter,impmve,de=lish,ormpAr
anyetmcture prlorto its lssuawe,aborequlresthe applicant forsuch permit to
file a signed statement that he b licensed pursuant to the provisions of the
Cont crorb Llcenselaw(Chaptar9(mmmmcingwith Sxckm7000)of Dlvt-
.Ian3 ofthe Business and Profesalons Code) orthat he is exempttherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant too civil penalty of not more than
flve hundred dollars (SS00).
F] 1, as owner of the property, or my employees with wages as their sale
compensation, will do the work and the simmers bnoHntended or offered for
sale (Sec. 7064, Business and Professions Code: The Contmetor's License Law
don not apply tarn owner olthroug his own employees,vets
who does
mentsawork himself ndedoraugh N.owne. If,hoe;er,thedildingthat h
improvement arenot ithinone earo(red platin, the however, deer ldinga
Improvement bwM within one yeamfcompletioR the owner -W Bderwilt have
tj(LJ LLyden of proving that he did net build or Improve for purpose of sale.).
as owner of the property, am exclusively contracting with licensed
contractors to congred the project (Sec 7044. Bualneas and Profeis dans Cade:
The Contractors License Law does not apply to an owner of property who
Wilda or improves thereon, and who contracts for such pto)ects with s
�gp�rector(s) licensed pursuant to the Contractor', Li... Law.
P C for this ason
LJ I am exempt under See. B k m
APPLIANCES -RESIDENTIAL i
JOB DESCRB'FION
PANELS
'
20140W AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
s/SQ. Fr.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MLSC
gF.V1P.METER ORPOLE INSi.
_
POWER DEVICES .
gNRMh9NGIWLELECI'RIC
OUTLETSSWITCHESFIXTURES L't`a4'Eo
V TION
NEW HFSIDENTIAL ELECTR SQ.Fr,
STO j�pTYPECONSTRUCTION
/
TOTAL; Go'—' --to
QTY, PLUMBING PERMIT FEE
�O�C, GgCUP
RES AMTS
PERMIT ISSUANCE
ALTER -DRAIN kVENT- WATER (EA)
FLOP5&0
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
pp(.y(JgES PER Tgpp
SANITARY Y N
RECEIPT p
Owner Date
heWORKMANCOMPENSATIONDECLIRATION
01reby affimr that I have a certl0ats of consent to self -Insure, ora
cenlficate ofWarkeri Compmmatloa Insurance a a certified copy thereof (Sec.
Mile, Lab C.)
Policy It
SCIgOOL TA% Y_ N
RECEIPT N
GAS, EA. SYSTEM -1 INCA OUTLETS
PARK y N
RECEPT N
GAS EA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DI VI SION FE IS
CertUed copy Is herebyfurnished.
Ccrtlf ed ropy b tiled with thee city inspection division.
Q
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(Thluecilon need not be complaled If the permit b(or ane hundred dollars
(s1I ftifyth
J not that In the pergmt in any mannerh. work so as to become subject to the
W Compenatlon lawn of Call(omla. Date
Applicant
NOTICE TOAPPLICANT: e, after making this Certnlpro is Exemption, you
should become subject to the Workw t Compensation provisions of the Latae
Cade, you rowed forthwith comply with such provtlons or thin permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lend Ing agency for the perform
anm of the work for which this permit b blued (Sec 3097, Civ. C.)
Icnder. Name
t<naer•.Addmaa
I mrtlfy that1 have madthis application and gate thattheabove Infom etles
Iscorred.I agree to comply with all city and county mdlnance.and nate laws
relating to building communion, and hereby author) a representatives of thio
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to ase, tndemmdly an d keep harndess the City of Cu pert Ino
agaWt llabaules,judgment,cote and expenses which may In any way scenic
ag�ld City in ..sequence of the granting of this permitCity in..sequence of the granting of this permit.
CREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recei I#
GRE'A'SE TRAP
SEWER -SANITARY -STORM EA. 20017.
WATER HEATER W/VENT/ELUCTR
ENERGYFEE Y N—
PAID
Date Recei t#
WA.IBRSYSTEM/TREATING
NEW RESID=- AL PLMB. SQ.FT.
TOTAL:
BUILDING
SEISMIC FEE
TOTAL
ELECTRIC FEE
s Ljo
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
O
PERMIT ISSUANCE s�
PEES PAID:
ALTERORADDTOMECH.
Date ReCei t#
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
AIR HANDU NG UNIT (OVER ID,000 CIM)
CONSTRUCTION TAX
SI wture of Appliant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building onvpant store or ha rad is haeardots
m
neatens as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ilealth and Safety Code Section 25532(a)7
❑ Yes f�j No
Will the applicant or future building ocmpanl use equipment or devices
which emit ham rdous air contaminants as dented by the Bay Area AU
Quality Management District?
4Yes�j No
havereadthe h.9usmaterials requimmentunder Cha pter6.95of
that Califomiallealth&SafMy Code,Sedions T5505,75533and2SS34.I
understandthal lfthe building does not currently have a tenant, that It b my
naponsibility to notify the occupant of the requirements which must be coat�s,
to issuance ola Certificate of0coupancy.
nem or aulhorired agent - Date
M(HAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 ITM
Dale RCCBIpt#
I]EATING UNIT (OVER IDg000 BTU)
TOTAL:
.a�
vs
VEN DLATION FAN (SINGLE RESID)
L55UANCE DATE
(J 7
a.�
-�`� of
MAOprior
ISSUED BY
-.7k,TOTAL:
BOILER -COMP (317 OR 100,0110 BTU)
BOILER -COMP (OVER 100,M) BTU)
NEW RESIDENTIAL MECH. SQ.FT.
OFFICE COPY