20927APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification 1
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PERMIT NO.
20927
where awe one:
TMAE=
PrrrVjLJ 5663-9
CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-MECTRICAI.PLUMBINGMECHAMCAL
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coat. me LVE
/
rc Ited neer. T1, No:
CATEGORY
CONTROL N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrees: -
❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IherebyIleensedunder provisions o(Chapter9 (
IngwthScdkm70W)o(Dv,eon] afthe BuslnnexiandPro(eWomCode,and my
license bin full forc�a tl .If
Li lam,
Clam -G •a([Lran
AIPLIANC6RESIDENIIAL
JOB DSRB+DON
PANELS
Date
Date ran dor
r
UPT02DO MIN.
271-1000 AMPS
ARCHITECTS DECLARATION
I understand my plaru.hall be used as public records
OVER 1000 AMTS r
SQ. FT. IT.00R AREA
5/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SI'ICIALCIRCUIT/
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt fromthe Contractor'• Licarw Law fm the
TEMP.MErMORPOL N
r
fallowing reason.(Sal.n7e3LS, Bushunwi ul Profession. Code: Any city.,
countywhich requ Tea a permit to mmtmd, al to r, Improve, dc=lbh, or repair
any°tmMmpr rtoltsbosamegaLwmquimsiheappliontfmmchpermitlo
file a signed statement that he Is licensed pursuant to the provbdom of the
POWER DEVICES .
gyar�hRN p,
Contractor. License U.(Chapter 9(mmmencing with Section 7000) of Divi-
don3 .(the BuNneoamd Profeselotu Code)orthet he b exempt therefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 7MIS by any
applicant fora permit °ubjectathe applicant to a civil perulty of not more than
OUTLETS HES I ES
five hundred dollars ($5M.
❑ I, as owner of the property, or my employees with wages as their sole
NEW R[SID E FdTR
STORIES
TYI'ECONSIRUCTION
compensatlon,willdothe work, andthe structure bawl intendedor offeredfor
_EEO
sale (Sec 7004, Business and Profemlom Code: The Contractors License Law
'
does not apply to an owner of property who builds or Improves thereon, and
who doessuch work himself or through his own employees, provided that such
f]CC.GROUP
RES.UMTS
Improvements are not Intended orof(ered for wk. If, however,thebulldleg or
Improvement bald withinomraro(compldlomtheowner-W llderwlll have
TOTAL:
thrt*rden of proving that he did not build or Improve for purpose ofeale.).
LJ L as owner of the property, am exclusively contracting with licensed
mntnd.rs to mnsbud the project (Sec. 7044, Business and Professions Code:
QTy, PLUMBING PERMIT FEE
FIOODPONE
APN
PERMIT ISSUANCE
The Contradors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who mntradk for such ptojeds with a
15dark) Banxd pursuant to the Contractors License Law,
1 am exempt under Sec B & P C for this resume
.
ALTER -DRAIN& VENT - WATER (EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
1 hereby affirm that 1 have a certlfiate of consent to self -Insure, or +
acitificalk ofWorkers' Comperwtlonlreurance ora certified mpythercof(Sec.
3800, lab C.) 2 it
Po11ryY 2�1
Com any y,�yp�r aka
ITX.IVRES PER TRAP
SCHOOLTAX Y_ N_
RECEER Y
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT M
GAS FA. SYSTEM-OVER4(EA)
BUILDING DI VISION FEES
Certified mpyb ereby 4911 •x%
Certlfled mpyb Ned with the city lnspedlon dlWslon.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANC14ECKFEE
GREASETRAP
CERTIFICATE OF MUM PFION FROM WOR KERS'
PAID
SEWER -SANITARY -STORM EA. XpFC.
COMPENSATION INSURANCE
(rhbsedian need not be completed lithe permit b forooe hundred dollars
Date RL'CY'.1 I#
HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
WWI or lase.)WATER
I mdlfy that in the performance of the work (orwhdch this permit b lowed,
I shall not employ any person In say manner m u to became subject to the
Workers' Compensation Uwe of California. Date
WATNi SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become aubject to the Workers'Comperwtion provbiom of the Labor
NEW RESIDENTIAL PLMB. SQ.FT.
Date Rsimi t#
TOTAL:
13UILDING FEE
Code, you at forthwith comply with such provbimu.,this pemdt Bhall be
deemed revoked. -
CONST RUCTION LENDING AGENCY
SEISMIC FEE
Ihembyaffirm that there is mperform-ELECTRIC a nstmotion lending agency for the perfo
ame o(the work forwMchthb ,mit b Issued (Sec. 3097,Civ.CO
Lender: Name L I � �
Lender's Addrre..
Iceril/ylhat l have radthb application and statethatthe above Information
bmmd. I agree to comply with all city and county ordinances and pate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MEC14ANICAL PERMIT FEE
MECHANICAL FEE a
^ ,eye
PFRMITMUANCE - (t W
FEES PAID:
relating tobullding construction, and hereby authaze mpeexntalives of thio
city to enter upon the abovcmenlloned property fm Wpedion purposes.
(We) agree to save, Indemally and keep harts the City of Cupertino
agabulllebillles' dgmenb re"w mayin nyway roue
Receipt#
�I
ALTERORADDTOMECH.
AIR HANDUNGUNIT'(TO IQOOOCFM)
SUBTOTAL:
against sada i nromeque ce the ntin ape it
AIR HANDLING UNTf(OVER 10,000CFM),
CONSTRUCTION TAX
Sig tureo Appilcant/Conlr dor Da
EIIHAITSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS RE
HEATINGUMT(TOl00p006T1p
Will the appllant or future building occupant store or handle h.rd.ua
material a• defined by the Cupertino Municipal Code, Chapter UZ and the
Health a ad Safety Codec
❑ Yes N
Date Recei t#
HEATING UNIT(OVER 100,000 BTU)
s�x�s
TOTAL: W
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
uedlou.25532(a)7
Wllltheapplicantor turebuilddngomupantuseequlpmentardeviare
which emit haeardous air contandnams as defined byline Bay Area Air
BOILER -COMP OFB' OR 100,000 BTU)
Qu Ilty Management DislilclAl
4ousoYea
nleriab requireen!sunder Chapler6.95 of
have read the haaa mrn
the Morrie Health & Safety Code, Sedions 75505, 25533 sad 25534.1
understand that if the building does not currently ve a tenant, that it is my
BOILER -COMP (OVIB410g000 BTU)
"
NEW RES]DFNTIAL MECH. SQ.Fr
responsibility to notify the occupant. ere at. wh lch must be and
priori is^ anu Certi(lateo sup ry.
,: r, �y90 /r rl�
J
ISSUEDBY:
Ownerorauthorbad agent I
n`j�
7OTA L: Old
OFFICE COPY