20768 APPLICANT TO FILL IN INFORMATION WITHIN-RED LINES — USE BALL POINT PEN ONLY
tlulldin Project memllkalan - PEILWT NO.
Building Address:
s �3� PEI 20768
Owners None:
CITY OF CUPERTINO-BUILDING DIVISION '
Ce aces: C�ck L . APPLICATION'/ PERMIT' :
Amhhect/ glneer. Lle
�+ .&Ia BUILOINC-ELECTRICAI TYLUMBIN'G-MECHANICAL CATEGORY CONTROL N
No:
- ' t'- 1 .'oktjBU1LDINC PERMIT4NF0 y;' "
Qir'•;' ;ELECTRIC PERMIT'. _ • FEE,.,; ....,... . ...
Address: - Pr"ThiSUANCE Ely 1:1 ' ❑.
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions ofChapler9(commmc APPOANCESRESIDENHAL JOB DESCRIPTION
ingwith Se an7000)of DiWsion3ofthe Busimmand Professions Code,and my
license is In full force end effect. PANELS s _
License Claes Lic.N • 7sa F ;
Date Cm1melor J,�
ARCHITECTS DECLARATION 201-IODOAMN
mZ IundentandmypbmshallbeusedaspubRcrecards. OVERIWIIAMPS - SQ.FC.FLOORAR A 5/SQ.FT.
OC SIGNSELECTRICAL
.Licensed Professional
FLa'7 OWNER-BUILDER DECLARATION r
' -
7p, � IhercbyafBrm that]ace exempt fromtheContnttar'aLirense law for the SPECIAL CIRCUIT/MISC
- ,
pp following mason.(Section 7031.5,Business and Professions Code:Any city or TR
O Z TEMP.MEIOR POLE INSf.
countywhich requlrcsapermittoromtmct,aller,improve,demolkh,orrepair
arystcom prior to inlsmance,also requirestheappl]cant for such perentto POWER DEVICES
O mfile a signed statement that he Is licensed pursuant to the provisions of the
3w Contractor's License Law(Chapter 9(commencing with Settlors 7000)of Divi- SWIMMING]'(IOL ELECTRIC VALUATION
sion3oflhe Businessand ProfemlansCMd )arthathekexemptthemfmmand
�n the bask for the alleged exemption. Any violation of Section 7ML5 by any
G F, ,
O
applicant drfora permibubjectethe applicant toadvll penalty of not morethan OUTLETS-SWITCHES�FIXHJRES
five hundred dollars(S50W'
NEW RESIDENTIAL ELECTR SQ.• STORIES • TYPE CONSTRUCT ION
'9..'
E]1,as owner of the property,or my employees with wages as the r sok IT.
CLQ compensation,will do the work,and the structure is not intended or offered for
y ❑ sale(Sec.7094.Business and ProfessionsCode:The Contractors License law
3$ does not apply to an owner of property who builds or improves themor,and OCC.CROUP RES.UNI'1'S
who doessuc a work himself or through his own employees,provided that such
improvements arc not Intended or offered for sale.If,however,the building or LOYAL:
improvement k sold within oneyearofcompktion,the owner-buRderwill have '
th,s.Lurden of proving that he did not build or improve for purpose f.ale.). QTY, 'hUMBIN R FP� ( •'.„ t�FEE" FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE -
contractors to ronstroct the project(Sec.7044,Boston.and Professions Code: '
The Contractor's License Law does nat apply to an owner of property who AL7772-DRAT &V -WA +
Wild*or Improves thereon, and who contracts for such pw)eae with a -
roy�g{TTactor(a)Banned pursuant to the Contractor's License Law. fCl"tl BBACKT T.D �t 'FEE SUMMARY t' '
E31 am exempt under Sec. B&P C for thin reason
Owner Date DRAIN RROOF,A A SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECF7IT N
FIXLJ*kRTRA�. ❑1 hereby affirm that I have a certificate of consent to self-insom ora s SCHOOL TAX Y N_
malfimte
3800,Lab
CJ o(Worken'CompensatlanWmnreora rertl(kd copythereof(Sec. RECEIPT N
GASSYSTEM-11&4EA. 0 PARK FEE Y N
3800,Lab
Policy RE)CEGAS EA.SYSTIM- VER4 MA DING'TN
Com any BUILDING DIVISION PCIS
certmed copy khereby furnished. . GREASE/IVDU LWA Erroll PLANCHECKFEE
❑cerBfW copy k filed with the sty inspection division.
CERTIFICATE OF IX^cMfT1ON FROM WORKERS' - GREASE PAID
COMPENSATION INSURANCE SEWER,SA ARV- P.A.200FPDate 'Racer t#
(This section need nd bs completed Bile,permit kfor one hundred dellen . P
(51Icnrfy the I cem esin the performance of the work for which this permit is mated, WATER HFAM W/VENT/ELECTR ENERGYFEE Y N
I shall not employ ayyn w'In any manner ro beco ro t he WATER SYSTEM/TREATING
Workeri co ape eSt96n Gwa of Gufncola. PAID
2 Z Applican �' NEW RESIDENTIAL PLMB. SQ.FI'. Date Reeel t#
O NOT1C OAPP ICANT' star nu ring aCertifl Ie of Exemption,you
should be mmesubjectt��1+J Workem'Compensatlon provklov ofthe Labor TOTAL:
V) Code,you must felt
hwltfi comply with such pmvklom orthk permit shall be -BUILDING •E
W > deemed revoked. DI G FE
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there k a constmciion lend Ing agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit k ksuei(See.3097,Civ.C.) TOTAL: _
L) OLender's Name - PLUMBING FEE
LL F Lenders address - QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE
O W ludifythatlhavemadthkapplkallonandd mthattheabtselnformation -
1 bcorrect.I agme to comply with all eltyand county ordinances and state laws - PERMIT ISSUANCE - FEES PAID:
r relating to building construction,and hereby authorize representatives ofthis ,
I'_ U) city to enter upon the above.mentloned property for Inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,indemnify and keep ass the City of Cupertino Date Receipt#
-against it blBtle dgments,costaandexpe a hich ma In anyway accrue AIRHANDLINGUNITGO10,000CRM) SUBTOTAL:
against said onsequenceoflhegr It
li,
AIRHANDLINGUNH(0VERI0,000CF'M) CONSTRUCTION TAX
S' nature of Applk /Contras ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MATERIALS DISCLOSURE '
Will the app] of or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Zi
I❑all'and Safety Code,Snell..2S532(a)7 HEATING UNIT(OVER 100,000 BTI!) TOTAL: C
No
Will theapplicant or❑future building occupant use equipment mdevices VENTILATION FAN(SINGLE RFSID) IS ATE
which emit ha ardous air,contaminants as defined by the Bay Area Air
Qu lit Management lJkMct2 BOILER-COMP OIE'OR 100,000 BIT)) II •I rr! yC'
nYes R 4Na sI U I`.
I love read the haOarnOYS materials requirements under Chapter 6.95 of BOMER.COMP(OVER 100,000 BTU) ,
the California Health&Safety Code,Sections 25505,25533 and 25534. 1 �s� .{
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. 'SQ.IT. ,Cly of Ilupetfknol
respomlbilily to Ify the occupant of there menisw kill must be mel
prior to bell a aCertificateofOaupa
vneroraut ori agent, Dat` ISSUED' W,
TOTAL:
OFFICE COPY'