20773APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT
Building Address:
V(
NO.
- 20773,_
one:
CITY OF CUPERTINO-BUILDING DIVISION'
APPLICATION I PERMIT
BUfLDINGELECTRICALPLUMBING-MECHANlCAL
L�
^^ ct �•Na= � LI,. N.
CATEGORY
CONTROLN
Architect/Euglim em Lie. No:
QTY ELECTRIC PERMIT" FEE
BUILDING PERMIT INFO
Address: A
❑ a ❑ ?moi
L�J
PERM171SSUANCE
LICENSED CONTRunder provisions
I hereby kaffirm that l iv licensedunderof Chaeter9(commen
IngwIM I. 7000)ol Dlvfect. fthe Butln 4 onsCpde, and my
Llcenae a L"If
Data le In ddfecl-I
yp
Date Contractor
ARCHITECT'S ATI N
I understand my plane shall be used as public records.
Licensed Professioral
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
following remon. l5ection 70:11.5, Business and Professions Code: Any city or
county which requires& pemetteconstruct, alter, bnprovqrm
deofish,orrepair
anyst mmprimtolbisvrame,alsorequimlheapphmntfmmchpermitto
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapler9(commencing with Stolon 7000) of Owl.
gon3 ofthe Business and Professio.Code)mthat be is eaempttherefromand
the Dais for the alleged exemption. Any violation of Section 70115 by any
applicant fora permit subjects, the applicant to a civil Family of not rrnre than
five hundred dollars ($SM.
I, 8. owner of thep roperry, or my employee with wages as thele dole
com(Sec. 7K Business aworkandlms Code; is not Intended or offered for
sale (Sec. 7011, Business Code; The Cimproves es hexed law
does red apply tornowner orproughhisrty onemorimprwvided that such
dthatsuch
who does mch am nothimselfdedoraughed owns. If,ho eq however,
improvements are not inlendeeyearofoompl tion,the ow owner
improvement bwidwithinoneyearofcompleliogtheowner-bu0derwW have
-builderwdl g orhave
Itic.iturden of proving that he did net build or improve for purpose of sals.).
LL�I L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Rumness and professions Code:
The Contractors Liecrue Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such ptofeets with a
cgptfactm.) licensed pursuant to the Contractor's License Law,
LJ I am exempt under Sec. R k P C for thisreason
APPL[ANCESRESIDENTfAL
JOB DESCRIPTION
PANELS
201-1ODDAMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
SPECLILCI2CUIT/MLSC
TpA{p METER ORPOLEINST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSNTTCHESFlXTURFS
VALUATION
'
'
NEW RESIDENTIAL ELEC SQ.FT.
STORES
TYPECONSIRUCTION
AL:
QTY. PLUMBI G ERINIT FEE
PERMIT ISSUANCE
ALTER -DRAIN k VENT- WA TE
OCC.GROUP
RFS. UNITS
FLOOo7DNE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FEES
DRAINS -FLOOR ROOF, AREA, OOND.
11XiVftFS PER TRAP
S ARY Y_ N_
RECEEPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
Ell hereby iffiren that 1 have a certificate of consent to seR-inure, ora
certifiateofW�orr�heryryes..'Compewtimimumnuma�rdificd m thereof face.
3800. NbC) (O_I
T TAX Y_ N_
RE�m'1• N
GAS F.A. SYSTEM -1 INC.4 OUTLETS
PARK FEE Y N
RECEPTN
GAS F.A.SYSTM-OVER4(EA)
Co an
�Y
Certlfied mpybhereby furnished. /I
❑ Certified copy V filed with the city Wpec on al(JI^.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisaection need nut becompleted BtM permit b fmone hundml dollar
(f1I ondifess.)
Icertl(ythat in the performance of the work for which this permit 1. issued,
1.1all not employ any person In any manner so u to become subject to the
Worked Corepemathm Lawaaf Callfomla. Date
NO LICE
NOICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Worken'Compensetion provisions of the Labor
Code, you moat forthwith comply with such provisions or this permit &hall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there le a coearuction lending agency for the perform,
once of the work for which this permit is Issued (Sec. 3D97, Civ. Q
L.rder'.Name
Lender. Address.
I certifythet I haveread thisappuat/onand nate thattheabm a information
Is correct. I agree to complyvelthall Ityand rounyomllnanma and state laws
relating to building construction, and hereby authorla, representatives of this
city to enter upon the above-mentlorad property for inspection purposes
(We) agree to save, indemnify an d keep harmlem the City of Cupertino
against liabilities, judgments, cartesnd expenses which may in any wayacemnAIR
agairat said City in con mi ence of the granting of this permit.
BUILDING DIVISION FEES
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recel t#
GRE ASETRAP
SEWER -SANITARY -STORM EA 20017
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date ReeeT t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFf.
v TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
l' PERMIT ISSUANCE
FEES PAID:
JALTERORADDTOMRCH.
HANDLING UNIT (TO I0,000 CFM)
Date ReCei t#
SUBTOTAL:
AIR HA NDLING UNIT(OVER IO,ODO CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date -
HAZARDOUS MATERIALS DISCLOSURE
Wifltheappuant orflture buudingoemtpant store or handle hazardous
material as defend by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)7
MY. �j No
Will theapplianl or future building oavpart.. cqulpment or devices
which emit hamrdous air contaminants as defired by the Bay Area Air
Quality MamgementDistrict?
4 Y No
read the hazy ❑❑ ms nuterlals requirements under Chapter6.95 of
N. rnle Health A Safety Code, Sections 25505, 25533 and 25534. I
unci dthatlityt. (t Ifyth os,. not currently have atenan4 that ltbet
Ilitymifthebh ant of urcqui held Which That met
n so R t f
a /7
Owner or authorized agent Dat
EKHAUS'T HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
3 HFATTNGUNIT(OVER100,000 N
TOTAL72
DU
VENTILATION FAN (SINGLE RESID)
IS ATE
-
J[ le) • !.^ SP
ja��
11i
�'�y.�►��.y�'`,l r�� -_
SSUEDB��'V
3 BOILER -CAMP OHP OR 100,0(IO BTU) /L'Aes
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Ff
TOTAL: 1
OFFICE COPY