20316APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO.
3 1 6
/00 KE /6
20316 0
G I
ars ams. Pharr;
?RQPE�gT/4E-S
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUrLDINGELECTRICALPLUMBINGMECHAMCAL
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0 (7 Igo
Contndor'sName: _ ,LIcNo,
CATEGORY
CONTROL M
Archftect/Erglnar Lic Nre
QTY ELECTRIC PERMIT FEE
..BUILDING PERMIT INFO
-
Address
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyoved under 30(th.BusJ nd Pmfh=sr9(mmmm
Ingwlth Section7gD)oI DlWalon3 ofehe Bualmmand ProfemlonaCade,andm
APPLIANCESRISIDENf7AL
pi)Nv�a/�/)p�Ba�.D/ply
licena Is in full fora and cited.
in
PANELS
-
Llanee Lle#
Date Comra.or
UP TO 2DDAMPS
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plana shag be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. Fr.
SIGNSELECTRICAL
Licensed Professional
SPWIALCIRCUT/MISC
OWNER -BUILDER DECLARATION
I hereby a(Orm that l am exempt from the Contractor. License Law fathe
following ... (Section 70315, Bust. and Profession. Cade: My dryer
e
counlywhich requires a permit tuccuu uct, alter, improve, demolish, urrepalr
Q D5
'
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/�• y
/
,
TEMP. OR POLE MST.
anystrudurc pdorto its Issuance,aborequlresthe applicant for such peroration
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 7000) of Diol-
alon3 ofthe Buslnessand ProfealonsCode) orthat he is exempt lherefmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
nt fora permit subjects the applicant too civil penalty of nor
applicant m
POWER DEVICES
„
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESF[KTURES
'
VALUATION
D / / Q
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRICTION
compensation, wBldothe wale and thertrudure is not Intended or offered forA'
ale (Bee. 7044, Business and Professions Code: The Contractors License Taw
/0
does not apply to an owner of property who Wilds or Improve thereon, and
who does such work himself re through his own employees, provided that such
Improvement are not Intended oroffercd for sale. If, however, the building or
Impmvementlas ldwlthlnomyearofcompletion,tMe er-buMerwillhave
tIIL, urden of proving that hedid notbulldorimprove for purpose of sale.).
LJ L as owner of the property, am exclusively contra..... with Ilana
contractors to construct the project (Sec 7014, Business and Professions Code:
TOTAL:
.,
s I;<d
QTY. '. E
BING:PERMITtFE
OCC. CROUP
RES. UNITS
FLOOD ZONE
APN
In ISSUANCE
The Centredoe. License law don nut apply to an owner of property who
builds or Improves thereon, and who cometas for such pipjeda with a
r�yjractor(s)Bcensed pursuant to the Contn.ots License Law.
LJ I am exempt under Sec. B k P C for this reasonOUTS%
ALTER -DRAIN is VFNT-WATER (EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
UP FEES
DRAINS. FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT #
Owner Date
WORKMAN COMPENSATION m DECLARATION_
❑I hereby affirthat I have a cedl0auurc
le of consent to selMn, or
certificate of Workers Compereatlon Insurance a a certified copy thereof(Sec.
Polic Tab C.)
Polley #
S�RTRAP
SCI{OOL TAX Y_ N
REC N#
GAS EA.SYSIEM-i INC.40UTLECS
PARK FEE Y N
RECEPT N
Com any
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
�S,ertNed mpylahereby (umlehtd
jaa C:erl EL ropylaflhd if1hthe city Ivpection d.Waion.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GRE-ASE7RAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SANITARY-S[ORM EA 2lDFT
COMPENSATION INSURANCE
('Thlssedion need not be completed if the permit b (Drone hundred dollars
Dale Recei t#
WATER ITpA.I.RR W/vENr/EI.ECTR
ENERGY FEE Y N
PAID
($100)aless.)
I artifythat in the performance of thework forwhlch this permit t Issued,
I shall ..a employ any persat in any manner so as to become subject to the
Worker: Compensation Iaw.of CalBomla. Date
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
NEW RESIDENTIAL PLMB. SQ.PT.
Date Recei t#
TOTAL:
L G FEE
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby afOrmtlut there las coretradlon leading agency teethe perform-
once of the work for which this permit is Issued (Sec. 3097, Civ. C.)
Lenders NamePLUMBING
Lenders AddressQTY:
1 certitythat I havereadthisappliationand alatethatthe above Information
Is correct.I agree to complywlth all etyand county ordinances and mate laws
TOTAL
ELECTRIC FEE
FEE
!MECHANICALPERMIT 'FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorise representatives or this
city to enter upon the above-mentWmd property for Inspection purpose.
(We)agree to am
ve,indenifyandkeepharmless the of Cupertino
against liabilities, judgment"sand, sand expenses which ue
amve which nuy In nywaya
ALTERORADDTOMICH.
'
Date Receipt#
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
ago Wtala In consequence or the gra nttg It.
owtA
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sigmume of p ant/C r a al
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
ATA MATERIALSDI SURE
HEATING UNIT (TO 100,OOD BTU
Date RDcei t#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)t
n4�Yea No
HEATING UNIT (OVER 100,000 BTU
TOTAL:
VENILATION PAN(SINGLE RESID)
ISSUANCE DATE
fll the appllant or lure building ompant use equipment or d evices
which emit loomrdous air contaminants as deReed by the Bay Area Air
Quality Management District?
jj''''�� Yes No
1 h ve read the haurr.usmaterials requirements under Chapter 6.95 of
the Glifomt Health k Safety Code, SM Ions 75505, 25533 and 25531. 1
understand that ifthe Wilding does not currently have a tenant, that It is my
p e
/—Alm
d :1 IyayV
BOILER -COMP Oh1P OR 100,000 BTU
BOILER -COMP (OVER 100,000 BID)
M
NEW RESIDENTIAL MECH. SQJT.
responsibility to notify the occupant of the requirements which must be met
-
prim to Issuance of a CenBlate of Occupancy.
City of Cnnerfinn
ISSUED BY-.,.,,fO KvC
Owneroraulhonzedagent DateTOTAL:
OFFICE COPY