20642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'crI identification T PE IMITNO.
Building Address: 20642
-5017-15'ners aces: �` ` one: A
(,J P O _ CITY OF CUPERTINOBUILDING DIVISION �^ .2---'FO
�f�
. C rator.N.me: Luc.No: APPLICATION /PERMIT v
to, BUILDINC-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL q'�,rr�/_
ed neer. LIc.No: (�V�CJ
lj�. DIQt'r4hJb J BUILDING PERMIT INFO
b/ 5( W/AI GFhf57Z.'X /D Qn ELECTRIC PERMIT FEE
Addreu: CJ PEtMITISSUANCE
LICENSED CONTRA OR'S DECLARATION 1:1 1:1 El
I hereby eBlrrri that l Am licensed under provisions of Chapter 9(commenc APPLIANCFSRE9DENI7AL JOBD RB'TION
ingwith Section 7000)of Dlvision3ofthe Businessand Pmfessl°nsCWe,and my
license b In full forceand effect PANELS _ ✓/ �a
Llcenx Class LIc.# r�
Date Contractor \ - "
ARCHITECTS DECLARATION 201-I000 AMPS
µQS O'CJC. I understand my plats shall be used as public records OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.F r.
E U Licensed Professional SIGNS ELECTRICAL q .g S
G w OWNER-BUILDER DECLARATION
I"n Fn SPECIAL CIRCUIT/MLSC
L, I Thereby affirm that lam excmpt(romlhe Contntorb License Law for the
Z 'Q� following reason.(Se tion 7MI.5.Business and Professions Code:Any city or
Fg countywhich tress permit tomnstrut,Alter,lm demolish,orce hMP.ME7TR0 LE IN
E Q reqs pe prove, pair
anystrutue prior to its hauance,atso requires theappBant for.uch permit to DOWER DEVI
p file a signed statement that he is licensed pursuant to the provisions of the
pgg,, Contractor's License (ChapterLaw 9(commencin with Sedum 7000)of DWI- SWNIMING IDOLE
VALUATION
"'30re^ sion3°fthe Businessand Procialons Code)orthaehebexem thercfromand '
ga yE� the basis for the alleged exemption. Any violation of Section 70G 1.5 by any O SWLrc H
❑ ¢i apptlomforapermitsubKostheappOcanitoaavilpevltyo(ntmmthan bVV
m 4Rye hundred dollars(STM. NEW R D E
? ❑1,as owner of the property,or my employees with wages as their sole `-QFL SIO TYPE CONSTRIKTION
compensation,wRldo the work andthe structure 13 not intended or offered for
Osale(Sec.7064,Busbtess and Professions Code:The Contractors License law
e$ does not Apply to an owner of property who Wilds or improves thereon,and
5^ whodoea such work himselforthmagh hisown employees,provided thatsuch OCC.GROUF RFS UNITS
Improvement.are not Intended°roffered f srsale.If,howevep thebullding or TOTAL:
Improvement usoldwithin amyearofcompinion,theowner-buRderwlll have
th `den of pmving that hedld notbuud crlmprove forpurposeofsale.). QTY, PLUMBING PERMIT FEE
LI,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
c°ntradors to congrut the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contrsdors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such ptojeta with a FEE SUMMARY
cq➢4[+dor(s)Ikensed pursuamtuthe Contrator'.Llcen.e Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for this mason
Owner Date S DRAINFLOOR ROOF,AREA,COND. SANITARY Y N_
• RECEIPT
OKIWORKMAN COMPENSATION DECLARATION FIXTURES,PER TRAP SCIiOOL TAX Y N
IJl hereby affirm chat I have certificate e a rtificale of consent eet(-Insure,ora RECEPF N
certifrate of Worken'Comperuation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
1, EPF
LabC RECN
Policytl_ Gl 7o sozl GAS-EA.SYSTEM10VER 4(EA)
Corrmany BUILDING DIVISION FEES
Certified copy is(fled withh the
ertifid copy hercbytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE /6
he city inspection division. `7 0
CERTIFICATE OF EXEM PTION FROM WORK ERS' I GREASE TRAP PAID
COMPENSATION INSURANCE BE-1yER-SAM.I.AIXY-51VRM EA 2o0F1' Date Remi I#
ffhlswomm need nt W completed lithe permit is forone hundred dollars
alm)or Tess.) wATEeI-�,TEX w/vFxr/E.ECTR ENERGYFEE Y_ N_
1 certify that In the performance of the work for which this permit is Issued, r2_o
I shall not employ any person In any manner An As to become subject to the WA t SY5177d/TREATING PAID
-
0
Gws°f Uh(°rnla. Date
O Z Applicant NEW RESIDENTIAL PM6. Q.FT. Date Remi t#
Z p NOTICETOAPPLICANT:If,after makingthla Certifcateof Exemption,you
should become subject to the Workers Compeosation provisions of the Labor TOXAL_ TM
cr N Coda you=at forthwith comply with such provisions orthis permit shall be BUILDING FEE
LU ] deemed invoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 7.
1 I hereby offirmthat there is a construmon lending agency for the perform ELECTRIC FEE
D Zonce of the work for which this permit is Issued&c.3097,Civ.C.) TOTAL:
00 Lenders Nam PLUMBING FEE
LL
Landers Address QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
O W Iced.Idglihavemad mply is with applicationand
cuntyoaunanceshe above information
1 brorret.lagreeto comply with all ndtyandcountyordreprese and gatelawsPERMIT ISSUANCE FEES PAID:
} cityrelat ng to oenterulpongcomuecricAioned eby opertyorl inspection
of this
N cityWenteree to the,indemnify an
property Wpe Cit purposes. ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cuperilno Date Reeeip[#
V against liabilities judgments,ociesand expenses which may in any way accrue AIR HANDLING UNIT aO 10,W0 CFM) SUBTOTAL:
ag�o lost>Bald City In conscryanM o t e grant Ing of this permit
/5F/..fr$'� l ���o�a AIR HANDLINGUNIT(OVER I0,000CFM) CONSTRUCI70NTAX
�`Igraam of Applicant/Contractor I Dote EX.USTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaamlous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iiealth and SAfdy Code Sed1on 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: .](/
❑ Yea, I]No
Will theapplicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANGE•DATE
which emit h.rardous air contaminants as defined by the Bay Area Air k-HN rix,
Q�La,lity Management District? BOILER-COMP OMP OR 100,000 BTU)
Yes ❑ rtter
No have read the hazardous siale requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)67V) 2 01990
the California Health&Safety Code,Sections 25505,2593 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESI DENTI AL MECH. SQ.FT.
raposibility to notify the occv pant of the requirements which most be met city CF Istt,arilRN
prior to anuance of a Certificate of Occupancy. �J
Owner or authorised agent - Date ISSUED
TOTAL:
OFFICE COPY If