23057r
APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Ruilding Pro'eat Identification
Building Address:
PERMIT NO.
20330
23057
one:
T"T
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING¢ECTMCALPLUMBINC.MECHAMCAL
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CATEGORY
C
s Lk. No
iZry ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PERMIT ISSUANCE
ly 1:1 X
LICENSED CONTRACTOR'S DECLARATION
Thereby ffirm that lant licensed under sprovisions of Chapter 9(mmmrnc-
ingwith Section7000)of Dlvislan3ofthe Bulnass.rd Pm(ealoneCode,and my
Bassese le In lu0(yce and eccef
APPLIANCES -RESIDENTIAL
JOB DESCRIIPIION
��aiaasa//
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PANELS
1 mCkss LIcne
��S
Conmtom
201-100OAMIS
ARCHITECTS DECLARATION
lundefstand Rrypkneshallbeusd aspublicremrda
OVERIODOAMPS IleSQ.
Fr. FLOOR AREA
$/e.Q. Fr.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm But I am exempt from the Contractor'slicense law for the
TEMP. METER OR POLE INST.
following mason.(SMion 70115, Business and Professions Code: Any city or
county which requlmsa permlttomrotmct, alter, Improve, dennlish,orrepalr
anystructure prior to its Issuance, also requlrestheappBeantfor such permit to
file a signed statement that he Is gcensed pursuant to the provIslom of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
,on3 o(the Business and ProfessionsCode) or that he las exempt therefromad
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant (ora permit subjects the applicant to a civil penalty of not morn than
ROWER DEVICES
SWIdhBNG POOL ELECTRIC
OUILETSSWITCHES-FIXTURF `
/ VALUATION
S `o t..1
five hundred dollars(WO).
QI, as owner of the properly, or my employee with wages as their sok
NEWRESIDENTIALELECTR SQ.k1jAR
TYPE CONSTRUCTION
compensation, willdothe work, and Destructure is not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
docs not apply to an owner of property who builds or improves lhemon,and
who does such work himself or through hisown employees, provided that such
OUT'
RIS. UNITS
Improvements are not Intended oroffercd foreale. If, however, thebuilding or
IssoldwithlnoneyearofcompldloMtheawner-bullderwill have
TOTImprovement
t rden of proving that he did not build or Improve for purpose ofsaleJ.
L as owner of the property, am exclusively contracting with licensedcontractors to construct the project(See. 7044, Busm adProfessions Code:PERMIT]
QTY, R ITTONE
U
APN
The Contractor's License law don not apply to an owner of property whoALTER-D
or Improve. thereon, and who contracts for such plojcs with a
licensed pursuant to the Contractors License Law.
c LJ I am'eempt under Sec R & P C for ihIs mown
IN &VENTWbuilds
d"1q➢!(acmr(a)
BAQ(FLOW PROTECT. DEV]FEE
SUMMARY
��Nqq--��--nimcinizruraDRAINS IT.C>�91WG
FDCPER .RAP
YNOwner
RECEIPTXWORKMAN
Date
COMPENSATION DECLARATION.
❑I hereby affirm that I have a certificate of consent to self -Insure, ora
mrtiflate o(Workena a
Compensation lrsu mor or a rtlfled ropy thereo((Sec.
3800, Lab C.)
Y_ N
RECEIPT p
GAS EA. SYSTEM -1 INCAOUTLETS
PARK F¢ Y_ N
-Policy N
RECEIPT N
CAS -EA. SYSTEM -OVER 4 (FA)
Cram any
BUILDING DI VISI IT ES
�Cartifted copy Is heed with teid.
®Certlfted copy Is (Teed with the city inspection dlvialon.
CREASE/INDUSRiL WASTE INTERCEPTOR
PLANCHECR FEE '(�a
GREASE TRAP
CERTIFICATEOFEXRMPTION FROMWORKERY
COMPRNSATIONINSUNANCE
(TNsansneed not be completed Ifthe permit Isfor one hundred dollar
PAID
Date /R..,pt!
gEWERSAMTARY-STORM EA 2(1(1RI•
WATER HEATER W/VENT/¢ECTR
EN' E N
/ —
(S10oJ Or leoss.).)
Icertify that tithe performance of the work for which this permit is Issued,
I shall not employ any person In any manner w as to become subject to the
Workcn'Compenmtlon La so(C.Ilfomla. Date
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Worker' Comperoatlon provisions of the Labor
_
D 10 Recei t#
NEW RESIDEN11AL PLMB. SQ.FT.
OTAL:
Code, you at forthwith comply with such provisions orthis permit shall be
deemed revoked.
B
ISMI FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the perform
ance of the work for which this permit Is Issued (Sec. 3097, Civ. CJ
_
RIC FEE 150
TOTAL:
lander. Name
Iandae.Address
I certify that I have read this application and stair that the above information
Is correct. l agree to comply with all city and county ordinances and state laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE �w
PERMIT ISSUANCE I ��
FEES PAID:
relating to building construction, and hereby authorise rcpreaentativea m th
city to enter upon the above-mentioned propertyforinapectlon purpose..
(We) agree to save, 1 demnlfy an d keep harmless the City of Cupertino
ALTER OR ADD TO MECIL `�
Date Re el t#
P
SUET TAL:
agabsth.blBtl jud V,cost. ands.;= which may in anywayamrue
.gainsId CI i en of the granting&thls permit.
AIR HONORING UMT(r010,000 CFM)
AIRIiANDLINc UNIT (oven lo,(0ocFM)
CONSTRUCTIONT
Sig rcof Appllant/Contra or Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION XPAID:
NA2ARD0 S MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant nrfuture building occupant store or handle hazardous
material as defined by the Cupertlno Municipal Code, Chapter 9.12, and the
Health and SafetyCdr , on 25532(.)7
❑ Ye
Date R Cel t#
HEATING UNIT (OVER 100,000 BTU)
T TA
VENILATIONFAN(SINGLE RESID)
ISSUAyCE. TE
p 1 {{J/
WI1l the appiicanto futurebuilding occupant use equipment ordevices
whichemi[hazardou. Ircontaminanla as deftned by the Oay Area Alr
BORER -COMP O}{I'OR 100,0(D BTN
Qualuy Mawgement Diat
n'
4 zaro Ye o
m
havereadthel stedatsrequimr ntsunderChapter6.95of
the Callfumisllealthk (MyCdr, Sections 25505,25533 and 25534. I
�3
BOILER-COMP(OVER 109,000 BTU)
NEW RESIDENTIAL MECH. SQ.IR
understand tha fthe uildingdoenat currently havealenanq that It is my
®EC A
responaibllltyt a] occupant of the requirements which most be mot
prior ua of Rate (Occupancy.
tKll
^it Ur V0
ISSUEDBY:
Own nor authorized agent Date
TOTAL
OFFICE COPY