20725AODI II`APIT Tn FH I IN IMFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
B°°ding Address: I
Ig3�3 �t vpwa Cu I'
PERMIT NO.
20725
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGFlEx7RICAGPLUMBING-MECFiAMCAL
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on do LIc.N.
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CATEGORY CONTROL#
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4'QTY
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: �
I PERhf1TISSUANCE[:]ElEl
LICENSED CONTRACTOR'S DECLARATION
I hereby affbmthat l amlicensed under provelonsof Chapteril(mmmm
APPLIANCMRE4DENIAL
JOB ESCRIIxp10N
-
PANELS
UP TO 200 AMPS
ingwlthSedlon7W0)uf Dlvlaion3ofthe BuslmuandPmfeWonsC-ode,andmy
limnse la 11 fug (o and dfect. S /
License m b
T
Date ^� ontrad.
ARCHITECTS DECLARAi ON IC
I understand my plana shag be used u public records.
a1\i1
201-1000 AMPS
OVER IOW AMf5
SQ. FT. FLOOR AREA
S/SQ. FT.
Licensed Professional
SIGNSELECTRICAL
6 SPECLILCIRCUIT/MISC '
OWNER -BUILDER DECLARATION
I herebyafBrmthat I am exempt fromthe Contradori License Law far the
following reason.(Section70315, Buslnmand Profevbre Code: Arycityor
counlywhich requires a permit toconermact, alter, improve, demaleh,orrepair
TEMP METER OR POLE INST.
,
anystm=mpdortalelssuame,WomqulrestheappbantforauchperMtto
file a signed statement that he is licensed pursuant to the provisions of the
Con tractors License Law (Chapter 9(commencing with Section 7000) of Divi-
Sion 3 of the Business and Professlore Code) orthat he b exempt therefromand
POWER DEVICES
SWIMMING POOLELECIRIC
ga-
VALUATION
the base for the alleged exemption. Any Violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
137 OUTLETSSWITC FIXTURES
five hundred dollars (ML
MI, as owner of the property, or my employees with wages u their...
compe... tion,wgldothe wok,and the trudure is em Intended or offered for
NEW RESID ALELECTR_SQ.PC.
WP
STORIES
'
TYPECONSTRUCTION
vie (Sec. 7046, Busbmae and Professions Code: The Contractors Wcense Law
,
-
does not apply to an owner of property who Wilds or improves thermn.and
who doesmch work hlmselforthrough his own employees, provided that such
OCC.GROIII'
TIES, UNITS
Improvements are not intended oroffered forsale. It how meq thebulldingmr
improvement eaold withinom)earofcompldbgtheowner-bullderwill have
the burden of proving that he did not build or Improve for purpose of sale.).
1:-J I, as owner of the property, am exclusively contracting with licensed
contactors to construct the project (Sm 7044, Business and Professions Code:
TOTAL:
P
RING PERMIT FEE
FLOODZONE
APN
CE
The Cantradol. License Law does no apply to an owner m property who
Wilds or Improves thereon, and who centrad. !a such p,jed. with a
cq➢t[+dor(.) licensed pursuant w the Contndars License Law.
LII am exemp under Sec. B h I', C for the on
Owner Date
L VENT- WATER (EA)
FEE SUMMARY
B W PROTECT. DEVICE
—OUTSIDE FITS
D FLOG R AREA, CONED.
SANITARY Y N
RECEBT N
WORKMANCOMPENSATIONDECLARATION
®I hereby a((Irm that I have a certificate of consent to self-Inwre, 0
certificam.4 Workers Compensation Insurance or a certfikd copy thereof(5ec.
3800, Lab C)
s
77X7X7UREa`
SCHOOLTAX Y_ N
RECEIVE N
GAS EA. l G.4ODILEIR
PARK FEE Y N
R�xT g
Po1kyN
Com any
GAS VRR4(EA)
BUILDING DIVISION FEES
�Cedlfiea copy b hereby fumlahe .
rlCedlRed copy to filed with the city Inspection division.
'-P' CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE/N ASTE INTERCEPTOR
PLANCHECK PEE
PAID
GR
SEWER- NIT Y -slow EA 2owT
COMPENSATION INSURANCE
TTMssection need not be completed g the permit a forom hundred dollars
(S1W)orless3
I certify that N the perfomanmof the work forwhich this permit Is erred,
I shall not employ any person In any manner w as to become subject to the
Workers Campenvtlon Laws o(GlRomla. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become'subject to the Workers' Compvuatlon provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
Date Recei t#
—
WATER HEAT02 W/VENT/ELGCTR'
ENERGYFEE Y_ N_
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL ELMf. SOFT.
TOTAL:
BUILDING
SEISMIC FEE
dmmed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there e a construction lending agency for the perform-
ance of the work forwhlch this permit a hissed (Sce. 3097, Civ. C.)
Lenders Nome
Lenders Address -
TOTAL:ELECTRIC
FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT
MECHANICALFEE
I artifythat I have read thisappllmtlonand datethal theabove InformationFEE$
Is correct. l agree to comply with all city and county ordinances and gate laws
mprentativen of the
relating to building conslroction, and hereby authorlx es
cityto enterupou the above-mentioned property for inspection purposes.
(We)agree to save, Indemnify and keep harmtev the City of Cupertino
against liabilities, judgments, mound expenses which may In any wayaceme
ag.mstaaid City in consequence of the granting m the permit
PERMITISSUANCE
LCO
PAID:
ALTER OR ADDTO MECH.
Date' Recel t#
AIR HANDLING UNIT (TO 10,000 ChM7
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
NSTRUCTION TAX
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
Signature of Applicant/Contractor Date
HAZA R DOUS MATERIALS DISCLOSURE
Will the applicant orfumerbuilding occupant store orhandleharardous
material as defined by the Cupertino Municipal Cade, Chapter 9.12, and the
Health and Safety Code Section 25532(a)7
0 Yea(� No
Will the applicant or tare building occupant use equipment or devices
which emit hazardous air contaminants as deBmd by the Bay Area Air
Quality Management District?
❑ YVa No
(. Ieaemad the haza oro materials requlrcmentsunder Chapter 6.95 of
-
HEATING UNIT CTO 100,000 BTU)
Date Re el t#
HEATING UNIT (OVER 1 WpW BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
FI
V�bT)'y¢
o
BOILER -COMP DEEP OR 100,000 BM
BOILER'COMP(OVDi 100000 BTU)
lons 25505,25533 and 25534.7
the California Health k Safety Code, Sections
understand that if the building does not currently have a tenant, that it a my
responsibility to notify the occupant of the requirements which must be mat
prior to issuance of a Certificate of Occupancy.CLI
Nov 1f7
,
Ice' •,
ISSUEDBY:7'
NEW RESIDENTIAL MECH. SQ.r.T.
Owner or authorized agent Date
TOTAL.
OFFICE COPY