20310APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro eat Identification
Building Address: _
1010 TUk.RE UE- N/ O D/•1
PERMITNO.
n O .O
G
nsra ante: e one:
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BU[LDING-ELECTRICALPLUMBING-MFCHAMCAL
A -
9.0
cnntractw•a
CATEGORY
CONTROL#
Architect/Engineer. Llc No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO—,
Address
jlx yip
LL F LJ
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebya(ftrmthat l am licensed under provisions o(Chapter9(commeno
tnalue I. ectlon force AnDlviect. (the Buelneseand ProfeWoneCode, and my
license I. in di.n7orce and A.1
License Gla® LILY
Date Contractor
ARCHITEC3`5 DECLARATION
Iunderstand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Ltmnw Law for the
following mason.(Section 7 31 BuainessndPrro(embneCode;snydittyor
tWcotmc"mpmv, emlihr
anystructum pdormits issuance,atsurequiresthe applicantforsuch permitto
file a signed statement that he N licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmmmoing with Section 7") of Divi.
cion 3 ofthe Business and Profmboa e)
Codorthat hats exempt therefromand
the basis for the alleged exemption. Any violation of Section 7015 by any
applicant for a permit subjects the applicant to a civil penakyof net more than�..J
five 1, dred as r.
($50he
R e ad owner of the property, or my employees with wages as their dole
sale ISM Bon, Business
ess andwork,Pr And the structure isnot Intended or offered for
dale (Sae apply to ainow and Professions Code: The or impmves thereon Law
docs not apply toanowrcio(property
rough who Wlporlmprwnthereoryand
who improvements
his own ale.It employees, providedabuilding or
am khimse dee or offered
intended earofcdpletio. the oweveptheerwIllgw
improvement is sold
Improvemonttssold wlthinoneyearo(complellorytheowner-budderwlll have
tlajZtrden of proving that he did not build or improve for purpose of Asia.).
u L as owner of the property, am exclusively contracting with licensed
contractors to maolruct the project Business(See 70KBusinessAnd Profeast°ro Code:
The Contradoes License Law don not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pwje� with a
License Law.
cgpt(�ctor(s) licensed pursuant to the Coninctor's Lice
1_J l am exempt under Sec B k P C for this mason
APPLIANCESRESIDENIAL
QC,�CgIpTTO
'
PANES
UP TO 2DDAMPS
201-10O AMP'
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
aS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MIST
TpMP.MElT3OR POLE INSC.ontywhhmqubea
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES,HXI'URES
/— VALUATION
/� I • QQ
/
NEW RESIDENTIAL ELECTR_SQ.FF.
STORIES
TYPECONS7RUCTION
TOTAL;
'. ',.". PLUMBING PERMIT FEE
OCC.CROUP
/1
-
RES. UNITS
,
QT'y,
PERMIT ISSUANCE
ALTER -DRAM & VENT -WATER (EA)
FLOOD TONE
APN
FEE SUMARY
M
BACKFLOW PROTECT. DEVICE
OUTS] DE FEES
DRAINS- FLOOR ROOF, AREA, GOND.
SANITARY Y_ N_
RFC®PT Y
Owner Date
WORKMAN COMPENSATION DECLARATION
QI hereby efflrm that I have a certificate of consent to .elf -Insure, or a
certificate of Workers'Comperoation Insurance oracertlfad mpythereo((Sec.
3CJ
PolicyN
FIXTURES PER TRAP
SCHOOLTAX Y N_
RECEIPT If
GAS EA.SYSTEM-1 INCA O117EC5
PARK FEE Y N
RECEIPT#
GAS EA. SYSTEM -OVER d (EA)
Com n
BUILDING DIVISION FEES
rtified copy ts herebytuMe city
Cert111ed ropy ts (Ikd with the Aly Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(Chis section need n°t be completed hf the permit B froom hundred dollars
($10)wlnA.)
. I certifymi
that in the performance ofthework forwhlch this pert is issued,
I shall not employ any person In any manner so As to become subject to the
Workers' Compensation Laws of GRfornia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Waders' Compensation provisions of the Labor
Code, you oust forthwith comply with such provisions or this permit shall be
domed revoked.
CONSTRUCTION LENDING AGENCY
Ihembyafflrm thatlhereba constructionlendingagenryt°rlheper(orm-
ance of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
L.ndar'. Name
U.&e.Addren
I mdifythat I have read thhappRationand eti tethat theab°veinformation
incorrect. IegreetocomplywBhalldtyandcountyordhnanceeandstalelaws
relating to building cnwtruction, and hereby authorize representatives of thio
city to enter upon the above-nanficned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
Against liabilities, judgments, rods d e.penxs which may hn.nywayacaue
agaWt what yor ena be an gofthhspe it
t ¢
GREASE/INDUSLRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Receip[#
GREASE TRAP
SEN'F.R-SANITARY-STORM P.A. 2110F1'.
WATER I{EATER W/VFM/Ef.ECTR
ENERGY FEE Y N
_
PAID
Date Recei t#
WATER SYs Em/7REATiNG
NEW RESIDENTIAL PLMB. SOFT.
TOTAL:
B
/
SEISMIC FEE
TOTAL:
ELECTRIC FEE
PLUMBING FEE
-- ,
Qrv, ",.. MECHANICAL PERMIT, - -FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEE$PAID:
ALTER OR ADD TO MECH.
Date - Rernipt#
AIR HANDLING UNIT (170 10,000 CPM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IQOOOCFM)
CONSTRUCTION TAX
Signature of Applhant Contractor ate
- HAZARDOUS MAT LS DISCLOSURE
Will the definedh pter9 hazardoud
ndbyt future ruin Municipal Code,
material ad defined by the Cupertino MuNctpal Code, Chapter 9.12, and the
Health and Safety Code Section 75537W7
❑ Yee N°
occupant we theequipmentArea devices
WllAn At appliausair contaminants
which fity Manavrdow firid? Mwnte ae defined by the Bay Area Air
�usilty Management IBdWct7
L� Yea ❑❑No
of
Ihaiforead Health
2menb5533 And 25534.
ardfet Protan Sections
the Californiatand tHealth k Safety Code, Sections 25505, have a tenant, gnathat I
unponsibidtyti(thfy the ocg Pus note reequirmentshichmust
It iset
resons1601 to soli theoccupantanto(the rerequirements which musl6e met
prior to Issuance o(a Certificate o(Occvpanry.
E(HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
.
HEATING UMi(TO 10,OD0 BTIl)
Date Rceei t#
HEATING UNIT (OVER 100,00 BTI!)
TOTAL:
VFM1LA710N FAN (SINGLE RESID)
1$ pN {DATE
'
City rat^ ,y
City I Im1I j1(?I IInn
ISSUEDBY: CC_
BOILER -COMP (3HPOR IOO,f100 BTU)
BOILER -COMP (OVER 10,00 BLU)
NEW,RESIDENTIAL METH. SQ.FI.
Owner or aulhorlud agent Data
TOTAL:
OFFICE COPY