20430 x
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
u
Building Project Identification PERMITNO.
BuRding Addrea,:vs 20430
one: A
CITY OF CUPERTINO-BUILDING DIVISION
IraNaVIP-me: L . oeAPPLICATION / PERMIT
_ "U.J
BUILDINGELBCTRICAL-PLUMBINC MECHANICAL CATEGORY CONTROL N
rchitect/Engineer: Lic.No
ger r'I '
`QTv, tEIECT ",) rcr. ' ' „'_,�? jBUILDINGPERMIT:INFO'- ° i`
'1 ' RIC PERMIT ' � � i PEG
PFRMITISSUANCE .❑ El
CONTRACTOR'S DECIA ATION
]hereby affirmthat l am licensed under provisionaof Ch.pter9(omm.c. APPUANCESRESIDENITAL J BDESCRRTION
Ingwlth Se on7000)OfDlvirion3ofthe Businesaand ProfeaslonaCode,andmy - -
lioudeb;n knocandeffect PANELS
Llcen l sat LIr.N 2 n O
Date Lt.t our J '�J
ARCHITECT'S DECLARATION 201-I0OOAMPS
00 I understand my plana shall be used sat public records. OVERIOOOAMPS .. SQ.IT.FLOOR AREA $/SQ.FT.
U0' Licensed ProfemlanSl •' SIGNS ELECTRICAL
6 - OWNER•BUILDER DECLARATION' SI'ECIALCIRCUIT/MISC
a^ G Ihereby affirm that Iamexempt fromthe Contmctor's Licenselwforthe
700.. following reason.(Sealon7R115,Busberoand Professions Code:Any city or
p4 countywhich rnqulmo a permit W ounsouct,alter,Impmee,denaelbTEMP.M17Et ORIOLE]NSI'.
h,or repair '
OOVanystructure primir,Its lawance,also requireethe appliantforsuch permitlo POWER DEVICES
a U file a signed statement that he b Licensed pursuant to the pmvblom of the
3�G Contractor's License Law(Chapter 9(mmmeneing with Section 7000)of Diel- SWIMMING POOL ELECTRIC
5 sloo3 of the Business end Podenlons Cod¢)Orthat he b exempt therefromand VALUATION
the basis for the alleged exemption, Any violation of Section 70315 by any GL>_
applicant fora permit subjects the applicant to a civil penalty Of OUTLETS-SWITCHES-FIXTURES
not more than
five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELFCTR Fr. STORIES TYPE CONSTRUCTION
7a- compensation,will dothe work and thestruturc b not Intended or offend for
O
We(Sec 7044,goal..and Professime,Code:The Contractors License Law
does not apply to an owner of property who Wilds or improve thereon,and _. OCC.GROUP RF5.UNITS
'who doeasuch work hlmrelf orthrough hls own employee,,provided that such
Impmvements am mt lntendea oroffered formle.IL however thebulldleg or TOTAL:
Improvement lssold wilhinoneyearofcompinuor,the owner-bullderwlll have
the burden of proving that he did not build or Improve for purpose of sale.). QTy, ", IPLW13(NG'PERMIT, I 'ti FEE '" FLOODZDNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMR ISSUANCE
rontmcton to censtrvt the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of property who gL7IIt DRAIN&VENT-WATER(FA)
Wilds or Improves thereon, and who contracts fee such ptokts with a
e ator(e)Imemind pursuaec.nt te,the Contraire.License Law. — t ,Li.,•,,' FEE,SUMMARY
I_J I am exempt under SB k P C for this reason BACK FLOW PROTECT.DEVICE
Owner - DRAINS-FLOOR ROOFS AREA,COND. SANITARY Y .N� -
Date RECIEPT N
WORKMAN COMPENSATION DECLARATION p0(TURES PER TRAP SCHOOLTAX Y N
ereby affirm that I have a certt(late of on
to self-ineurc,ora RIiCFJPf M
ifiate of WOrken'Compeusationlreuranceora certified ropythemof(Sec. GAS BA SYSI'EMIINC.40UTLEfS PARK FEE Y N
800,fab CJ -
Policy N RDC M=N
Com any - GAS EA.SYSTBM-OVER4(EA) - BUILDING DIVISION FEES
Certified copy is heed withfurnished,tcity GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
nullified copy b filed with the tlty Inspection division.
a
CERTIFICATE OFIO(EMPTION FROM WORKERS' CRFASETRAP .PAID
COMPENSATIONoINSURANCE SEWER-SANTfARY-STORM EA 200Ff Date Recel tH r
(fhb section bOromp]tN need not pltithe permit b farovs hundred dollars
(f100)offy that
work
WATER HEATER W/VENT/FLECTR ENERGY FEE Y N
]certify that Uthe performance of tAewmklarwMch this pemNtla bared, —
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TR1iATING .
Wmkue Compensation Lawsof Califomla.Date PAID
C• Z Applicant
Z U NOTICE TO APPLICANT:If,after making this Certificate of Feemptlon,you NEW RESIDENTIAL PLMB._SQFf. Date Reeei tN
Fshould beromesubjet to the Workers'Compensation provblons=LaborCC TOTAL:
W Code,you must forthwith comply with such proWlOru orthb permitshallbe BUILDING a.
W ] deemed Invoked. -
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I henbya(flrmthat there lata mnstrurtion lending ag Of for the petomm TOTAL: ELECTRIC FEE
Z ante ofthe work forwhichthe,permit b Issued(Sec.3097,CIv,C.)
(.) 2 Lentler:Nam PLUMBING FEE
LL Lender'.Adder. QTY. , MECHANICAL.PERMIT'',, ', FEE, , MECHANICAL FEE
U I retilfythat l have road thisappliationand tlnt¢thattheabove in(ormotem -
W. bcormt.I agree to complywlth all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
} V) relating to building construction,and hereby authorize rep sentatives ofthis -
?0 city to enter upon thea ex.menti p rtyforl Ion purposes. ALTER OR ADDTOMILH. - -
(We)ogre¢to ve ndemni an dl harmi the City ol,Cu pertlno Date ReceipNl _
(.I against llablWl d menti, sande nsea ch may In anyway acrzu¢ AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against Bald '¢ re it antis this permit.
AIR HANDLING UNIT(OVER 10,000 CEN) CONSTRUCTION TAX .
ig turn dAppiiant/Contractor Date EHAUSTHOOD(W/DUCT) 'CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous TREATING UMT(TO100,000BTU) Dat RCCCI tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code�u+.�Setion2S532(a)7 BEATING UNIT 100,000 BTU) -TOTAL; •�
Yea fis NO - '
Willi the hamolntor tum building occupant by theequipernotArear davits VBNHIA770N FAN(SINGLE RBsID) ISSUANCE DATE
hfch emithaement air contaminants as defined by the Bay Area Air IBJ
Illy Management Dist BOILER-COMP p]B'ORIOO,IXp BTIn
�Li�Y¢a ❑No }��
Ihyesmadthe hazardous materials requirements underChapter6.95 Of BOILER-COMP(OVER 100,0(0 BN) ciI of rUJJPrtjnry
the Cailfornia licalth $a! Code,Section 25537 an 25534.1 - - ..,,v�
untlemmnd that i( but ng dose menti asses nL that ltbmy NEW RESIUF1J77AL MGCH. SQ.IR. - ..
ropowibllity to Ify eoccupan them hfch must be nuM
prior lO sears fa rtlflcate co ,, '
r thorized agent - Date
- TOTAL: ISSUED _
OFFICE COPY