20309APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proert Identification
Building
jo/D^, tREAVE. UN 1T- 10 bb -
V
PERMIT NO.
- 20309
(Jwrar. `a one:
A
Q E'f27"7
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
Contractor'. Name: Lic. No:
BUILDINCvELECTRICALPLUMBINGMECHAMCAL
CATEGORY
CONTROL M
Architect/Engin.. Lk. No:'
QTY ELECTRIC PERMIT, 'FEE
BUILDING PERMIT INFO
Add.
BIG
te�r/
' 7I
PERMTISSUANCE
CONTRACTOR'S2
LICENSED DECON
I hereby fflnnthatlammsed underprovisions ofChapter cone-
ingwthSisio3oftheBwlumdProCelvCDdeadm
APPLIANCES-RESIDENTIAL
B.
.l�
FSCyg'RyI�Tr_I
license la 1.full (mme And effect.
PANELS
/
License Claw 0
Date Contador
UP TO 2DO AMPS
KII
701-1000 AMPS
ARCHITECTS DECLARATION
I understand my plane shall be used as publicremrda
OVERIOOOAMPS
SQ. FF. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
$[+ECIpL CIliCl11T/MLSC
OWNER -BUILDER DECLARATION
I hereby affirmthat l am exempt from the Contractor's License Law for the
following reason.(&RIon7031S, Buslnenand Prolmimo;Code:Anydtyor
rountywhkh requires a permit tocom uct, Alter, irnprove, demolhh,orrepair
V iU
` I
TEMP. MEIEROR POLE INS(.
anystmmmpdartoiuh ance,ahomqulmtheappllant ursudipermitto
file a signed statement thin he Is licensed punumt to the provisions of the
Contractor's License Law (Chapter 9 (commenclirg with Section 7000) of Divi-
non3 of the BInesem
usd Profewlow Code) orthat he is eeempttherefromand
]OWER DEVICES
l
SWIMMING 100E ELECTRIC
- VALUATION
the bash for the alleged exemption. Any t tolatlon of Section 7MISmem re any
app8andfon permit subjects the applicant to a dull penslty of not more Ilan
dollars($50M.
flue as pr).
FIT, a. owner the property, or my employees with wage as their Mole
OUTLEISSWITCHESFIXfURES
`J /� , D6
NEW RESIDENTIAL ELECTR SQXT.
STORIES
TYPE CONSTRUCTION'
will work.and the Wended oroffered
,/
(Sec. .Cdurehnot
Ask &c.mmpons70K Business and License Law
Code: The ..Law
�/ 'V
TOTAL:
doe to or impdale
don not apply to an owner of property who n Ills or Improves thereon and
apply f property
who dvnents such amrkMm.elf nded oraughhhowne. If,ho employees, uildinthat sch
Improvementsarenot incenomyearffercdfar Male.I4h er-bufldeulldinave
Improvement haold withinoneyearofcomplNlon,iheewner-bu8derwlll have
OCC. CROUP
n
' 1 V
RFS. UNITS
try�u ,den of pmving that he did not build or Improve for purpose of sale.).
LJ ,den
owner of the property, am exclusively contracting with licensed
contradon to construct the project (Sec, 7064, Busmen and Professlon Code:
QTY..::, PLUMBING PERMIT '. FEE
FLOOD TONE
APN
PERMITISSUANCE
The Contractor's License Law don not apply to an owner of property who
W. or Improves thereon, and who contracts such pkojeats with •
dor(s) licensed pursuant to the Conlradofe License Law.
am exempt under SB k P C for this ...
151am
-
ALTER -DRAIN &VENTWATER (FA)
FEE SUMMARY
BACK FLOW pROTpLT.DEVICE
DRAINS FLOOR ROOF, AREA, CONTI.
SANITARY Y_ N_
RECEIPT Y
Avner Dee
WORKMAN COMPENSATION DECLARATION
E31 hereby affl. that I have a certificate of consent to self -insure, or a
urtifitate ofWorken' Compensation Imurmm or a certlfbd copy thereof (Sec.
3800, Lab C.)
Policy N
FIXTUNES PER TRAP
SCHOOL TAX Y_ N _
RECEIPT g
CAS EA.SYSl4f-1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
Coany
GAS EA. SYSTEM -OVER 6 (EA)
BUILDING DIVISION FEES
❑ed ropy Is hereby furnished.
(ECAftified copy is filed with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
• CERTIFICATE OF EXEMPTION FROM WORKERS,
PAID
COMPENSATION INSURANCE
(Thhsedlon need not be compidd Bethe pernot b (Drone hundred dollars
Date Recei I#
SEWER -SANITARY -STORM EA. 2001
WATER HEATER W/VENT/n TR
ENERGY FEE Y N
PAID
(S100)orlew.)
I cartity that N the performance of the work for which this permit is Issued,
I shall not employ Any person In any manner An as to become subjcd to the
Workers Compensation IAws of California. Date
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certifiate of Exemption, you
should became subject to the Workers' Compersatkw provisions of the Labor
Date Recel t#
NEW RESIDENTIAL PLMB. SOFT.
TOTAL:
BUILDING
.0
Code, you mud forthwith comply with such provhbns or this permit shall be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is a construction lending agency forthe pedormry
ante of the work for which this permit le tastiest (Sec. 3097, Civ. C.)
Iendcrb Name -
Lendrea Addm.
I cenilythal I haveread thhapplIati.e.nd datelhat theabove Information
Ica cormd.I agree to complywlth all cttyand counlymdinances and pate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
o;
o
.,z: 1-.
QTY: -,'; ``MECHANICAL PERMIT ; � FEE
MECHANICAL FEE -
PERMIT ISSUANCE
FEES PAID:
relating to W ilding construction, and hereby authorize representatives of this
city to enter upon the eb.v mentl.oed property for inspection purpose..
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
agamst liabilities, Judgments, mneand expense. which may in any wayaccme
ALTERORADDIDMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CIM)
SUBTOTAL:
rO
againstMald Infpos enca h an Ing olthb permit.
S/� Jp�
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signature.(AppBant/C.ntrector fDhte
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
KAZARDOUSMATERMSDISCLOSURE
HEATING UNIT (M 100,000 BTU)
Will the appllcant or fours building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I lealth and Safety Code Section 25532(a)?
YesN o o���j
Rill the applkanl or rite building occupant use equipment or devices
Date ReCei t#
HEATING UNIT (OVER 10BM BTU)
TOTAL:
E:7
VENTILATION FAN (SINGLE REBID)
i�Ut: DATE
which emit hazardous air cmtaminanta a. defined by the gay Area Air
Quality Management District?
4Yes❑No
havcleadthe luccal s;maedalerequlnementsunderChapler6.95of
the Califemn HeethkSafdy Code,SMIom25505,25533and25534.I
x
t r I•V I:, 1
Jl
I.
BOILER -COMP (3HP OR 100,000 BTU)
BOILERLOMP(OVER I00,000BTU)
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the Wlldingdoes not correctly have a tenant, that it ismy
responsibility to notify the ouvp.ct of the requirements which must be met
City of Cnaertino
prior to issuance of a Certificate of Occupancy.
LTUEDBY.
Owner m authodzed agent Date
TOTAL:
OFFICE COPY