20480 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PF71\11T NO.
Building Address:
DD p 20480
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t /ed 'Ia�G'� -eA CITY OF CUPERTINO-BUILDING DIVISION
Shia; Com a CA
APPLICATION /PERMIT ��r,�i0
Y BUILDING-ELECTWCAL-PLUMBINGMMiAMCAL TEGORY CONTROLM
P-rchn /Engineer, Lk.No:
F7 Add..ADLV dlt� 04'e- �wol Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLUG ELELI PLUMB MULTI
rFxwns$uANCE ❑ ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION
here 'hat
Iam BonunderprovisionsofC
9(cemmmc APPUANCPSRFSDENTIAL JOB DESCRIPTION
Ingwlth5ection700)o(DiWYon3 oftheBuslnessand ProlessionsCode,and
my
Date Is In fu8 came ddfe<t PANELS
I.Icense class �Llc.I 314 7
Date_ �y,. ContradorUP TO 2DO AM
2011000 AMPS (fy'
ARCNITECI'S DF.CLARA N OVER 1000 AMTS SQ.FT.FLOOR AREA S/SQ.FT.
0 420 I understand my plans shaU be used u public records
r� (� Licensed Professional SIGNS ELECTRICAL
a<m OWNER-BUILDER DECLARATION
In�Fn SPECWLCIRCUIT/MLSC
7 Iherebyafflmn Contractor's exempt Coraor's License Law for the
Zt.., "x following reason.5ortion 7MI5,Business and Pmfemions Code:Anydty,or TIMP ME1JZ OR POLE INST.
countywhichrcqulresapermktoanstrod,alter,improve,demolish,orrepalr
a1.a anystadum prior to lb bsuance,aLw reyuireseheappBrant forauch permit to POWER DEVICES
r a U file a signed statement that he b licensed pursuant to the provisions of the
0wContractor's License Law(Chapter 9(commencing with Section 7X0)of Devi- SWIMMING POOL ELECTRIC
30 Yon3 ofthe Business and ProfemlonsCode)orthat he b exemptm
therefroand VALUATION
<
H3
S the baa.far the alleged exemption. Any violation of Section 7mt5 by any
'i
u�« I/
❑ aPPlicant fora permit subje tidv
the applicant too civil peltyda room than OUTLETSSWITCIiFSFIXTURES
five hundred dollars($M. NEW RESIDENTIAL ELEC7R SQ IOItILS TYPE CONSTRUCTION
f R I,as owner of the property,or my employees with wages as their sole
compensation,w0ldo the work and the structure is not intended or offend for
psale(Sec.7044,Business and Professions Code:The Contradoes License law
j5$ does not apply to an owner of property who Wilds or improves thereon,and CCC_ RFS.UNITS
doessuch work himself or through hisown employees,provided that such
improvements are not intended oroffered for sale.IL however,thebuilding or TOTAL:
improvement b sold within oneyear ofcompldion,the owner-builder will have
thA*rden of proving that M did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
L-i L as owner of the property,am exclusively contracting with licensed PEBMITLSSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contmorm s License Law does not apply to an owner W property who
Wilda or Improves thereon, and who contracts for such psojeds with a ALTIILDRAIN&VENT-WATER(EA)
TTI
BeorgA pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
TFEE SUMMARY
o
J f Sr.am exempt under B A P C for this rc
awn DRAINS FLOORROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIVE M
WOR"AN COMPENSATION DECLARATION PX.TC�S PPR.I.�Is SCHOOL TAX Y_ N_
❑I hereby affirm that 1 have a certificate of consent to self-Inwrc,ora
RECEIVE X
reNficzteofWmkrra CC'o/m/pens/^attoninuurance orq.cediftedeapythereof(Elec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,lois C.) ®V7Y 7J ^,7{7G�
Com any r &� GAS EA.SYSTEM-0VERd(FA) DING DIV]
Ep
BUILDING DI V(BION FE IS
�crrtmearopy b hereby furnished. / PLANCHECK FEE
Sartlfied copy b filed with the cityWpeedon division GREASE/INDUSTRL WASfEIMTRCFPTOR er
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANI'CARY-STORM FA.2XFT. Date Rcoef t#
('hissedion need not be completed B the permit b for..hundred dollars
($100)nrless') WATER HEATER W/VENT/ELFATR ENERGY FEE Y_ N_
I certify that in the performance ofthe work forwhich this permit is Issued,
I shall not employ any person in any manner n m to become subject to the WATER SYSTEM/TREATING
Workeri Compensation laws of Callamla.Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei t#
Z O NOTICE TO APPLICANT:II,after making this Certificate of Exemption,you
F Nshould become subject to the Workers''Compensation provisions of the Labor TOTAL:
_ Code,you at forthwith comply with such provide.or this permits hall be BUILDING FEE / 17
dermad revoked.
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebyafBrmthat there ba construction lendingagenry forthe performroTA1: ELECTRICFEE
Z ante of the work for which this permit is Issued(Scr.3097,Civ.CJ PLUMBING FEE
(� O lenders Name
LL f ]ender.Address QTY. MECHANICAL PERMIT FEL MECHANICAL FEE
0 W I cemlythatl have read thisappBotionand Yate thatthe above information
brewed.I agreeto comply with all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
C relating to building construction,and hereby authortxe representatives ofthb
Zcity to enter upon the abovtrm otoned property for inspection purposes. ALTERORADDTOMECH. Date RfCCIPt#
V — Mae)agree to save,indemnify an d keep harmless the City of Cupertino
ago Illtim,pd s,aYsandespen..s hichmnyinanywayaccrue AIR HANDLING UNIT(TO 10,"CEM) SUBTOTAL:
lost d4Ci Is< ns enmo(lhrgr n fogy LpermB.� CONSTRUCTION TAX
/_ _ d AIA HANDLING UNIT(OVER 10,000 C)T1)
go ere of App n Cont actor /�— Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
RDOUSMA IALS DISCLOSURE
Will the applicant or future building pantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recet t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the '—
I Its lth and Safety Cade�..Saection 25532(a)? HEATING UNIT(OVER]00,X0 BTU) TOTAL:
E❑ Yes L_I No
XIII the a pplicam on future building odupast use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit lurardous air contaminants as defined by the Bay Area Air &'AID
Quality Management District? BOILER-COMP PHP OR 100,000 BTU)
Yea No q
ve read the Nazar ou materialsrrquircrrcnb under Chapter 6.95 of BOILER-COMP(OV[R 1X,000 B1T1) (4MY 3 U 1990
the Ca rola Health&Safety Code,Sections 25505,25533 and 25574.1
and to that ilt 'Iding does not arrently have a tenant,that it b my NEW RESID=Al.MECH. SQ.FE.
m i t n Ityt eocateof ofthe uircnenL•which mus^t be1 tlme't1 p,�of p--__1__
pion ' 1 reocct of Occu S+/_/ V _ 4�141I�JBQ�F�W((IV/
P ra ho o agent Date ISSUHDBY:—W �s
TOTAL:
OFFICE COPY