20979APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building )'rated Identification
Building Address:) Q (-tOO se a c� �.
PERMIT NO.
20979
wnero ante: -1., one:
5't Y rt' 1 �,
CITY OF CUPERTINO-BU1LDING DIVISION
APPLICATION / PERMIT
q— /' qlo
I l^ --1
Contractor Name: LIc.No:
BU(LDINGELECTRICAL-PLUMBINGMECF(A MCAL
CATEGO CONTROLE).o(
b
Architect/Engineer. Lie. No:
QTY ELECTRICPERMIT FEE -
BUMOING PERMIT INFO
Address:
��{'a ❑ .
�/B �I
I PERMITISSUANCE L.W
LICENSED CONTR
-
under provisions
I heh Sedtolrmthm lam licensed under nessand ro ChapleCode,and
Inense I Sedfon for. and offoon3otthe BuslnessandPro(eulonsCde, and my
sodas I. m ram r-_$ �d erect. ,r
Licenen Cl ss Lick �1 .3 5395
Date/0 �— �O Contractor Jas" Se dde9 . C W ST
MPLIANCESRESIDENRTAL
JOB DESCRB'TION
1 PANELS
TrPTQWAbQ
201 1000 AMTS
AACHITECT9DECLARATION
I understand my plan shall be used u public records
Licensed Prn(eelorsl
OVERIOOOAMPS
/c-�Q� FT. FLOOR AREA
gqOEP
f/SQ. Fr.
2t,tex)
SIGNSELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby afRrm that I am exempt from the Contractor's License Law for the
TEMPMETIMORPOLEINSC,
following mason. (Section 7RMIS, Business and Professions Code: Any city or
county which requma a permit to construct, alte, improv, demolish, or repair
any atmos re prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of TIM.
slon3otthe Business and ProfessionsCode) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7MIS by any
applicant for a permit subjedsthe applicant too civil penalty a.. mare thanIts-l'J
POWER DEVICES
SWIMMING POOL ELECTRIC
'j
OUTLET&SWITCHE&FIXTURFSr
VALUATION
Q _,,•
NEW RFSID=AL, RLECTR' ,FI.
five hundred dollara WOO).
❑ I, as owner of the property, or my employees with wages as their sole
'
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is not intended or offered for
sale (Sec 70K Business and Prof cations Code: The Contractors License Law
TOTAL:CID
does not apply to an owner of property who builds or improves thereon, and
orthrough hlsownemployms, provided that such
Improvements are not intended oroffered formic. If, however, thebuilding or
Improvement is sold within oneyearof complelon, the owner-bullderwlll have
OCC. GROUP
RFS. UNITSwhodceasuchworkhimself
tlil,tiurden of proving that M did not build or improve for purpose of sale.).
LI 4 as owner of the property, am exclusively contracting with Is Code:
contractors toronsWctthe project (Sec. Business and Professions
QTY, PLUMBING RMT FEE
PMWITWUANCE .wi
CP
FLODD ZANE
APN
The Contractor's es the law don net apply to an owner of property who
app) Is
buil or Improve thereon, and who contain for such plojects with a
eter(s) licensed pursuant to the Contraor'sLicense Law.
off,ct
LJ 1 am exempt under Sec B & P C for this masonOUTM
ALTER -DRAIN & �)
c
BA FLOW PR T. C
FEE SUMMARY
DE FEES
DRkFIS FLOORR P, ND.
s
FIXTURES -PER Pk 2ss{P
SANITARY Y_ N_
RECEIPT k
Owner Date
WORKMAN COMPENSATION DECLARATION
1-11 hereby affirm that I have a certificate of consent to self -Insure, or a
certificate of Worliers'Comperwtion Insurance era certllied copy thereof (Sec.RECEIPT
3900, lab C.)
SCHOOLTAX Y N
M
SA.
GAESy C1011,PARK
FEE Y_ N
Policy k
GAS G.AV i )
BBC= If
Com any
BUILDING DIVISION FEES
Cedffled copy ls hereby furnished.
Certified copy Is filed with the city inspection division.
CREASE/IND A 1
PLANCHECK FEE
GREASE
CERTIITCATE OF FXEMPFION FROM WORKERS'
COMPENSATION INSURANCE
section need not d completed I(the pemdt ls for one hundred dollars
PAIDQ�,•,t7O 7se1 Gf�
1 Date ,R`ecei t# �/j%
1�Qhis
SEWER-SANrrARYS1ORM EA
(SI00) tifyth
(certify that the b his esubjecrmit I. Issued,
trunner
WATER HEATER W/VENT/ . TR
ENERGYFEE Y N
so as to
o person in an
I shall not employ any Laws 1n any runner n u to berome subject to the
become
Woakcan Compensation Laws o1 California.iDate
Applicant
NOTICE TO APPLICANT.IL after making thisCcABF-Tt.fEn,you
should become subject Workers'Compensation proisonssofthe Lab
Cod,you most forthwith comply
deenrd revoked.
WATER SYSTEM/TRTATING
PAID_
a
Date Recei t#
NEWRESIDENTIALPLMB. SQTI.
TOTAL:
BUIL ING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there ls a mnstruefon lending agency for the perform,ELECTRIC
once.fthew°rkforwhichthisper tlsbsued(Sec.3097,Civ.C.)
Rndces Addmm
Ievellythall have readthie appliationand stale that the above Information
la correct. l agree to comply with all city and county ordinances and state taws
TOTAL: Q,
FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE Q
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relml ng to building construction, and hereby authortee representative of no
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d M
keep harmless the City of Cu peno
against liabilities, Idgments, crass and expenses which may In any way accrue
against u d City in ronsequence of the granting of this permit.
_JerAIR
f ^� 9P
ALTPR OR ADD TO MECH.
Date Reeei f#
P
AIR HANDLING UNIT (TO 10,IXID CFM)
SUBTOTAL:
HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
gna lire of ZARDtrador —)j etc
AZA RDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Will the defined by or upbuilding occupant store hapten le 91Z and the
material as defined by the Cupertino MunldpalCde,CFapter 9.17, and the
Date RCCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Healthand Safety Code Section 25532(x)?
❑ Yn No
VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will the applicant a future building occupant use equipment or devices
which cent ha,eardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yes No
BOILER -COMP (3HPOR 100,0(0 BTU)
BOILER-COMP(OVER100,000 BTU)
have read the hazaWo s materials requirements under Chapter 6.95 of
the California Health & Safety Cod, Sections 25505, 25533 and 7553x. 1
understand that lflhe building does not currently have a tenant, that It is my
'
;t 1- �taso
I d n
NEW RESIDENTIAL MECH. SQ.F1.
responsibility to notify the occupant of the requirements which must be men
V1599
s
prior to issuance of a Certificate of Occupancy.
..�. -- _ /v -I-�r2.
f�4! of Glsga a�
Owner or uthor' agent Uate
ISSUED BY:
TOTAL:
OFFICE COPY