20949APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification `'
Building Address: ryZ /� sT-� a
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PERMITNO.
20949
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CITY OF CUPERTTN0.BUILDING DIVISION
APPLICATION I PERMIT
BUILDING -ELECTRICAL PLUMBING-MECHAMCAL
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°;.Name: ' 1 Lie. No:
O.
CATEGORY
CONTROL X
'
itect/Rn fie Lk. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PQ4MITISSUANCE Z
11 � o o
LICENSED CONTRACTOR'S DECLARATION
Ihereby
edionmthat lamllcm3oftheustnes provisions
andP of Chapter
ssions9(mmmme-
ingwlih Sect1on7000)ofDdelon3ofthe BugneseandP (eeslonaCode, and my
license bIn 4,N'( died
License ClaL► Lic,X
Dates 1d– Q.1�Contratlor
0 �r r(/AACHITE D CURATE N
I.ruidsland myplarashallbeused es public eecarda.
Licensed Pmfesslonal
OWNRR-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
fallowing ... (Section70315, Business and Professions Code: Any city or
countywhlch requima permit tummtmd, alteq Improve, demolkh, ormpalr
anystructure priorto its Issuance, also requlrentheappllcant fmrsuch permit to
file a signed statement that he is Bcense i pursuant to the provisions, of the
Contractor's License Law (Chapter 9(commencing with Section 7000)of Dlvl-
sion 3 of the Business and Professions Code) orthat he isexempt there(romand
the baste for the alleged exemption. Any violation of Section 70315 by an
applicant fora permit subjects the applicant to a civil penalty of not more lha
five hundreddollam(SSDO.
❑ I, as owner of the property, or my employees with wages as their sok
rompensatlon,wW do the work and the structure is not intended or offered for
sale (Sec. 7044, Busbies. and Pmlessima Code: The Contractor. License law
does not apply tom owner of property who Wilds or improves thereon, and
doeseuch workhlmself orlhrough hisoven employees, provided thatwrch
Improvements arc not intended oroffered forsale. It, however, thebuildingor
Improvement b sold withmoneyearofcompletloo, theowner-bullderwlllhave
t4r4arden of proving that he did not build or Improve for purpose ofvk.).
u I, as owner of the property, am exclusively contracting with licensed
rontmeton to co.tmd the project (Sec. 7044, Business and Professions Code;
The Contradoes LiceLaw does not apply to an owner of property who
Wild. or Improves thereon, and who contracts for such ptojeda with a
on ctur(s)Ilcenxd pursuant to the Contractor's License Law.
IJ 1 am exempt under Sea B & P C for this reason_
/
APPLIANCES -RESIDENTIAL I�C.�
JOB DFSCRII'RON
UPTOPANEI9
707-1000AMPS
OVERIODOAMPS
7 SQ. Fr. FLOOR AREA
S/SQ, Fr.
SIGNS ELECTRICAL
SPPrGlCIRCUIT/M1SC
TQ.iP METER OR POLE INST.
POWER DEVICES
SWIMMflNGPO0LELECT C
d OUTLETS -SWITCHES -FIXTURES �, I I� MC
VALUATION
NEW RESIDENTIAL ELECTR FT. /
SQ.FT.
TYPE CONSTRUCTION
TOTAL: a�
QEY, PLUMBING PERMIT FEE
,CROUP
RFS. UNITS
FLODD7ONE
APN
PERMIT ISSUANCE
ALTER -DRAIN & VENT - WATER eEn)
FEE SUMMARY
BACK FTAWIPROTFOT. DEVICE
nIITq'nH FEES
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES- PER TRAP
SANITARY Y— N_
RD2EIPT X
Owner Date
WORKMAN COMPENSATION DECLARATION
[:]I hereby affirm that I have a certlfiate of consent to self -Insure, ora
3800, Aifi te .. Workers Compewatianlreuranaoacertifled ropy thereof lsec.
3LaC.I
Policy M
SCHOOL I" Y— N_
RECEIPT X
S
GAEA. SYSTEM -]INCA OUTLETS
PARK FEE Y_ N
RECEIPT p
GAS EA.SYSTEI-0VER4(FA)
y
Com andt
BUILDING DIVISION FEES
CgRi is hereby th the .jEtCcity
Itled ropy k (Elect with the city Imapedion division.
' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cm M becom
Rhis session need fiat completed tithe Permit l9 (arcane hundred dollars
($100)orless3
Icertlly that In the performance o(the work forwNch this permit le issued,
I shall not employ any person In any manner so u to become subject m the
Workers' Compensation lawa of California. Date
ApplicaNOIICnt
Nould W. APPLICANT: It, after making this sti.. Certificate of Exemption, you
Code, you forth to the ply with such provisinpmvbimaofthe Labor
Code, you must forthwith comply with such provisions orthls permit hall be
deemed invoked.
CONSTRUCTION LENDING AGENCY
I herebyafflrm that there is a comtmctlon lendlegagenry forthe perform-
.am .(the work far which this permit e, Issued (Sec. 3097, CIv.CJ
Lander'. Name
Lenders Add..
Icertltythatl have readthas application and gate lhattheabove information
lecorred. I agree to comply with all city and county ordirato... nd state laws
relating to building mnstructlmn, and hereby authomm representatives of this
city to enter upon the aboveamenlloned property for Inspection purposes.
(We) agree to save, Indemnify an d kmp harmless the City of Cupertino
agaWtllablli , dgmenl.,d :,.tn ex cases whichmxylnaoywayacdae
agaimtsal Ity oonaequence aft rating ofthis permit
2/QQ
rg®t 01APPilant/ one or Date
aHA R US MATERIALS DISCLOSURE
illtheappBntor rc building occupant store or handle hazardous
terfal as defined by t upertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Sedlon75532(a)7
❑ Yea No
Will the applicant or NObuilding occupant use equipment or devices
which eMt hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
4 Yes nNo
have mad the haza mus materials requirements' under Chapter 6.95 of
the California Health& Safety Code, Seed es 75505, 25533 and 75534. 7
understand that fit ulldingdoesnot rmotly have a tenant, that It is my
responsibBityi Ify eoceupant a mqulmmenls which must be met
prior tin lssu cc oto iflal of panty.
Own o nzeda fit Date
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
PAID
Date Recei tN
GREASE'1'RAP
SEWER-SANDARYSTOREM EA 7(017
WATER HEATER W/VENT/EECTR
ENERGY FEE Y N —
PAID
Date Recei tic
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ17.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
a
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
,
ALTER OR ADD TO MECH.
Date Recei tN
p
AIRHANDLINCUNrr O'010,ODOCFM)
SUBTOTAL'
'
AIR HANDLING UNIT (OVER IO,WDCFM)
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
HEATINGUMT(TO100,000BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
�O
VENTILATION PAN (SINGLE RESID)
CE DATE
p ��
hR`faD+aMH
ISSUED BY:
BOILER -COMP OIBPOR 100,000 BTU)
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Fr.
-
TOTAL:
OFFICE COPY