20741 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Prom Identification PIILNITNO,
Building Address: 20741
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nets ante: one: A
N1 P CITY OF CUPERTIN0.6UILDING DIVISION O
Contractors Name: — sac.Noo APPLICATION / PERMIT I W 1
Z BUILDINGE.FCTRICAL-PLL BIN' ME l AMCAL CATEGORY CONTROL x
Architect/Engine,. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ptD ❑ �X� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION IrT
I hereby affirmthat l am ficenaed under provisions ofChaptcr9(mmmenc APP11ANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith5etbn9(IW)ofMvision3ofthe Businessand Pmfe msCode,and my
license is In full ffy - effect �[...� PANELS
License Cls%y C.r aJContr `r -�
Date ! Contractor 2011000 AMPS
UP TO 2DO AMPS
ARC hall be used
as p ORATION OVER I OOO AMPS SQ.FT.FLOOR AREA $1SQ.FI.
iJZ I understand my plans shall be seed n public rerords
�OL
j Licensed ProfeProfessionalSIGNSELECTRICA
Q OWNER-BUILDER DECLARATION SPECIALCBRCUIT/M19C
L., (hereby affirm'hat l am exempt from the Contractor's License law for the
O$t.3o following reason.(Section 7071.5,Business and Professions Code:My city or TEMP.hfEPFR OR
W county which requires a permit to construct,alter,improve,dertnlbh,cur repair
qr .'6,-i any structure prior to its Issuance,also requires the applicant for such permit to POWKIZ DEV(
15 a U file a signed statement that he Is licensed pursuant to the provtslons of the ,
pQ�O 4 Centractore License Law(Chapter 9(commencing with Section 7000)of Divi-
sion3ofthe Buslnessand Prfenloro Code)orthathehexemptthemfromand NG I00 CTRL 1, VALUATION
< the basis for the alleged exemption. Any violation of Stolon 7031.5 by any O TS-SWI
6660 apphrantfora permit subjects the applicant to a civil penalty of not exreflum
R�a five hundred dollars(ISM. NEWR ALELECTR .FT. STORIES IYPECONSTRUCTION
j.. n L,as owner of the property,or my employees with wages as their sole
C7a compensation,wBldothe work and thestruclure is not Intended or offered for
5 0 sale(Sec.70K Business and Professions Cade:The Contractors License Law
does not apply to an owner of property who Wilds or Improves themon,and OCGGROUP RES.UMTS
whodaessuchworkhimself orthrough hisownemployees,provided that such
Improvements are not intended oroffered forsale.ILhowevegthebulleingor TOTAL: ,Q
i provereent lsseld withinoneyearofcompletlo0.theowner-buBderwlll have
t1io.¢aNen of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
IJ L as owner of the property,am exclusively contracting with licensed pp�(pp ISSUANCE
contractors to construct the project(Sec.70,14,Business and Professions Code:
The Contractor's License Law does not apply to an owner a property who
Wilds or Improves thereon,and who contracts for such pRojM,with. ALTER-DRAIN&VENT-WATER SEA)
cgp(ract.o.)licensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE FEE SUN'1MF2Y
L�I am exempt under See. B&P C for this reason FEE5'
DRAINSFIAOR,ROOF,AREA,COND. SANITARY Y_ N_-'s.
Owner Data RECEPTa
WORKMAN VSATION DECLARATION �.URFS PER.T. t SC1dOOL TAX Y_ N_
MI hereby affirm that I have have a a cerclRate of consent to self-insure,ora RECEIPT X
certificate of Worker.'Compersation Insurance or a certified copy thereof(Sec. GAS PA.SYSTEM-1INCA OUTLETS PARK IEE Y N
3800,Lab C.)
Policy a RECEITT a
Com any GASEA.SYSTFMCWER6(FA) BUILDING DIVISION FEES
gCertlfied ropy b hereby fumished. GRCASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
oCcrified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MFT Date RCCeI t#
(Thlasecron need nes be completed If the permit Is for one hundred dollars
($100)orlese') WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I cer ifythat N the performance of the work for which this permit Is issued,
I shall nm employ any person in any manner n v to become subject to the WATIR SYSTf]tS/TREATING
Worker C.n,,..ationlawsof Callfoml+. Date PARD
0Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after makl eg this Certificate of Exemption,you
should became subject to the Workers'Compensation provblens of the Labor TOTAL:
N Cade,you must forthwith comply with such provisions or this permit shall be -BUILDING FEE
� j deemed revoked.
IJJ F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE CC
M Z a non of the work for which this permit is Wued(Sec.3097,Civ.C.)
00 Lenders Name PLUMBING FEE
LL H Iendcr'a Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO Imdifythatlhavercadthbappliatio..ndstatothattheaboveinfornatlon
Sill a Iscormet.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. (L tobulldtng construction,and herebyauthorloireprescntativesofthis
F N city to enter upon the abavcmentloned property for Wpection purposes. ALTFRORADDTOMECH.
Z (We):lice to save,Inde n d kee h:rMcxx the City of Cupertino Date RCCCIJJ[A
V ago Wtllabillt nnnt co nd ex xs whlchmaylnanywayaccme AIR HANDLING UNIT(SO 10,000 CFM) SUBTOTAL: b
agave yin n en fthe rung of this permit. CONSTRUCTION TAX
AIR HANDllNG UNIT(OVER 10,000 CEN)
Sigitaftiff of AppBant/ n Date D(HAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA OUSMATERIALSDISCLOSURE
Will the applicant or tum building occupant store or handle hasardous HEATING UNIT(TO IOLOOD BTU) Date Recci tM
material as defined bythe Cupertino MunicipalCode,Chapter9.12,and the ••�y ..I3��
I lealth and Safety Code Section MM532(s)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑Yes En No {),A
Will the applies cal orfutum build Ing occupant use equ 1pment or devices VEN77LATION FAN(SINGLE RESID) IS$ ATE
which emit ha,ca rdous air mora minants as dell ned by the Bay Area Air J
Quidity Management District? BOILER-COMP MIT OR 100,000 BTU)
ProYes F-I No
4havemad the haea'r�0usmaterials requirements under Chapter&95 of BOILER-COMP(OVM100,000BTU)
the California Health&Safety Code,SecHov 25505,25533 and 2553,1.1
u ndersta nd that ifthebuildingdoesnacurrently haveatenam,thath ismy NEW RESIDENTIAL MECH. SQ.17
neapovlbaity to notify the occupant of the requirements which most be met City Ot Cupertino
prior m issuance of a Certificate of Occupancy.
Owner or authorised agent Data TOTAL: ISSUED
OFFICE COPY