20748 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prned ldemlfiotianS I�� PERMIT NO.
B°°ding Address: 20748
ID7etre amt. one: IAL WAIL
,4#164 CITY OF CUPERTINO-BUILDING DIVISION G
Contractor's amt: Lk.No:
APPLICATION if PERMIT
7 �+ BUILDING-ELECTRICA4]'LUMBINGMECFIAMCAL CATEGORY CONTROL M
Archl cct Banter. 3b3.-3i7•- LIc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: FEMTISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I heh SocUo irmthatl ivigmseduederpessand ofessio sCode,mmmc API'[.IANC6RESIDENTTAL JOB DESCRIPTION
In ease 1.full form of d effect,
ofthc Buslnessand Pro(calonsCwde,and my
license Is In s 'torte and dfect. PANFIS
7,IcenseC ssL' LIC.R Z6,3.3!_'x—
,�" _y_;,,_cono-ad°r .� mv1UDO AMrs .
ARCHITIiCTS DECLARATION UP IQ 200
N 7 l understand my plans shall be used as public records. OVER I ODO AMPS SQ.Fr.FLOOR AREA 4/9Q.Fr.
COC
�+ o Licensed Profeaslonal SIGNS ELECTRICAL
<Cm OWNER-BUILDER DECLARATION OF
�n IASPECIALCIRCUIT/MLSC
f., 7 Thereby affirm thatlamemeopt from the Comedo/s Liame Law for the
0 O F^ following reason.(Section 70315,Be,[..and Profession.Code:Any city or TT2dp.MErIR OR POLE INST.
romm
countywhicli requiresa perttotruel,alter,improve,demolish,orrepair
anystmmmpdortolbbmance,aborequlrestheapplinnt(orsuchpermitto POWER DEVICES
E� 5 rile a signed statement that he b Bernard pursuant to the provisions of the
Contractor's License Law(Chapterg(commencingwith Section 7000)of Divi-
'"OOr<n olon3oithe Business and ProtelonsCode)orthatt he b exemptthercfemand SWIMMING IDOL ELECTRIC "
bash for the alleged exemption. Any violation of Section VALUATION
7031.5 by any
GOU7LETSSWI7CHESFIX7UIZE5
applicant fora permit subjectsthe applicant o a rnll penalty of rad nnre W n
p. five hundred dollars($SM. NEW RESIDEN71AL ELECTR STORIES TYPE CONSTRICTION
1,as owner of the property,or my employees with wages as their sok
f='�< compensation,willdothe work and thestrudu ,is nes intended or offered for
$ ❑ sale(ec.7044,Business and Profmiom Code:The Contractor's License law
$ does not apply to an owner a property who Wilda or improve thereon,and C.GROUP RFS.UNITS
does such work himself or through his own employees,provided that such
Improvements are not Intended oroRered forsale.IL however,thebuiiding or
Improvement bsold withinoneyearofcompidioNthe owner-builderwlll have
it(BJNrden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT E FTAOD ZONE APN
u I,a owner of the property,am exclusively contracting with licensed
contractors to construct the proj (Sec.7014 Business and Professions Code: PERMIT ISSUANCE
M
The Contractor.Llanse law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or improves thereon,and who contracts for such p3ojem with a
c�7jWumr(s)Hamed pursuant to the Contvdor's License Law. FEE SUMMARY
U I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE ITTS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner rang Date re or a RECEIPT'X
WORKMAN COMPENSATION DECLARATION FIXTIJRES PER TRAP SCIi00L TAK Y N
❑I hereby,form that I have.rertNcate of concent m sell-ince RECEIPT M
cedifimteof Worke Cwmpensaionlnsu maceditkd ropythereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.)
RECEIPT p
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any
ertl0ad copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
erilBed copy b filed with the city Inspe<lon division.
CERTIFICATE OF EX::MPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE $EWER-SANITARY-STORM EA 200F7 Date Relsi l#
Rhlsaedion need nes be completed if the permit b for one hundred dollars
(5100)0,les,.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I mAifythat in the performance of thework forwhlch this permit Is bowed,
I shall not employ any person In any manner se,a to become subject to the WATERSYSTEM/TREATING >
Workers Compensation Laws of California.Date PAID
0Z Applicant NEW RESIDENTIAL PCMB. SQ.IT. Date Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
F� W should become,subject to the Workers''Compemat Ion provisions of the Labor TOTAL:;
Code,you most forthwith comply with such pronslons or this permit shall be BUILDING
darted FEE
revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL F3 I hereby afgrenthat there b a construction lending agency for the perform- - TOTAL: ELECTRIC FEE
Z once.(the work forwhic this permit b iasued(Sec.3D97,CIv.C3
U O lander'.Name .1 PLUMBING FEE
LLH 1<ndcr's Address �- QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W 1 certifythat I have mad this applieitionand Aatethatthe above Information
0 ^ �y�
a Is correct.I a gree to comply with all city and county ordinances and state laws PERMIT ISSUANCE � J...� FEES PAID:
relating to building construction,and hereby authorize representative of this
r W city to enter upon the above-mantlonedpropertytorbupectlonpurpoms. ALTM- ORADDTOMECH. 2,
Z Date Receipt#
(We)agree to av ndemnly an d keep harMeaa the City of Cupertino ��yy�3
V agalnstllabilltlea,' g rats,copcand expenses lchmayinanyw.yaccrue AIR HANDLING IIMI(TO l0,lT10 CFM) SiLR+ SUBTOTAL:
a
fast said City c moot the calf Pa. /J AIR HANDLING UNTIT(OVER 10,000 CFM) CONSTRUCTION TAX
7�n 7//L
Sigmm ofA cant/ omractor Data- 1 � EXHAUST HOOD CW/DUCT) s ce CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 1
Willtheapplicam or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) D Date Recti f#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I ealth and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ YesNo
Willtheapplicantoruture building occupant useequlpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haca doses air contaminants as defined by the Bay Arca Air
. Quality Mavgemcnt Mind? BOILER-COMP OHPOR 100,000 BTU)
Yea 11��I No
lhaweadthehazammsmatedalsrequimwntsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 2:534.I
understand that it the building does not currently have a meant,that it b my NEW RESIDENTIAL MECH. SQ.FT. . O 19Ap
U
responsibility,to ratty the ectu pant of the requiremenb which must be ,ai�� <• i+
prior to evaa f Ccr�J(Icattee of OcyR nq.
W�k
ser o sed ag rat Date ISSUED BY:
TOTAL:
OFFICE COPY