20774 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification ((yy PERMITNO.
Building Address: 0 as I G 20774
me
Oat
( l 'If`L A A
PIS and
Name: CITY OF CUPERTINO-BUILDING DIVISION
ue.N APPLICATION / PERMIT ��`J �
• a o C BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL Y
Architect - ginmr. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑ I�
LICENSED CONTRACTOR'S DECLARATION X
I hereby affirm that l am licensed under provisions ofChapter9(commune. APPLIANCEPsRESIDENTIAL JOB DFSCRE'IION
ngwlth Section7000 f 'viW..3ofiheflmine....d PIDfessioos Ccda,andmy
conte C # / �S C PANELS 1..7�"/�LI
Date Lk.p [ cJ ' l'V✓�T'
Date Contractor mi IOOOAMPS
ARCHITECTSD fA IO OVER IODO AMPS SQ.Fr.FLOOR AREA E/SQ.FT.
o
1qq+� I undenWnd my pWtr shag W used u public rccods.
a W,1 Licensed Professional SIGNS ELECTRICAL
�Cce OWNER-BUILDER DECLARATION SPEOIALCIRCUT/MLSC
t.., IherebyafRvn that l am exempt from the Contractor's Lt...law for the
OZ1-� following mason.election 71111.5,Business and Profession.Code:Any city or TEMP.METER OR PO NST.
c.unywhich rcqubeaa permittomnatruci,ilter,improve,derrolWh,.rrepilr
Qany structure priorto its Wuance,also requlreathe applicant forsuch permit to ]OWER DEVICES
file a signed statement that he is Deemed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 700D)ofDivi. SWIMbENGPOOL CT VALUATION
O slon3 ufthe Business and Prefessloos Cede)orthat he Wexem Iherc(romand
EvS�yd the basis for the alleged exemption. Any violation of Settles 7031.5 by any OUTLETSSWITC
Da applicant for a permit subjects the applicant to a civil penalty of not marc than
live hundred dollars(5S", NEW DEMIIAL TR .FT.
I,as owncrof the property, y employees w wage.as S'I'ORIIS TYPE CONSIRUCIIDN
p perry,.r m . with wn their cote
7�]Q compenution,willdolhe work andtheswc4ure Wnot lnlended or.(lcred for
�+O sale(Sae.7004 Business and Professions Code:The Contractors License law
$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RES.UNITS
who docssuch work himself orthrough his own employm,provided that such
improvementsare not intendedoroffered forsale.ILhoweverthebuilc egor TOTAL
improvement i.wldwlthln omrarofcompidiogtheowner-W Ederwlll luve
th-qJurden of proving that he did not Wild or Improve for purpose of ule.). QTy. P BING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mmtruct the project(Sec.7040,Business and Professions Cods;
The Contractors Licensee Lew dm me appy to an owner d property who
Wilds or Impeavm thereon, and who contracts for each projeM with a ALTER-DRAW k VFM-WATER
c'q➢I��ctorts)Emoted pursuant to the Contractor.License I . BACK FLOW PROT[CT.DEVI FEE SUMMARY
IJ 1 am exempt under Sec. B k P C for this masonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA, D. SANITARY Y_ N_
Owner Data RECEBT p
WORKMAN COMPENSATION DECLARATION pp(TUltgq.I'ER TRAP SCHOOLTAX Y_ N_
F11 hereby aflirtn that I have a certificate of consent to self-Insure,ora RECEIVE B
Ocertlficme ofWarkers Com ruction Insurance orae ied co thereof c. GAS EA.5YSTEM-1 INCA O ETS PARK FEE Y_ N_
3800,lab C.) /v �J �S V RECIII''T B
P.IIryX 1,.� 01 ✓ IIIJJJ CAS EA.SYSICM-OVERd(FA) BUILDING DI VIS I ON FE ES
L_JCertlfiedcopy Whdebyfurnished I REASE/iNOUSTRLWASTEINTERCEPTOR PLANCHECK FEE
-1 Certified copybflled with the cl 1 on dl ISI n.
CERTIFICATE OF EX( PTION FROM WOR K ERS' GRFASETRAP PAID
'�. COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI Date Revel t#
(This section need not W completed Blhe permit Is forme hundred dollars
($100)°rless.) WATER HEATER W/VENT/FI.ECTR ENERGYFEE Y_ N_
I mrtify that N the performance of the work forwhich this permit is ixwed,
1 shall our employ any person In any manner on as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of CalBomia.Data PAID
OZ Applicant NEW RESIDENTIAL PLMB, SQ.FT. Date Recei tq
Z 0 NOTICETO APPLICANT:U,after making this Certificate of Exemption,you
should become,.b)ect to the Workers'Compensation provWinro ofthe Labor TOTAL:
cc in Code,you must forthwith comply with such provenorn or this permit shall be BUILDING FEE
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there Is a mrotruction lending agency for the perform TOTAL: ELECTRIC FEE
tiism
Z ams the work which this permit is ed(Sec.3097,CIV.C3 PLUMBING FEE
V O 4nder'e N.ma
LL F Luedd'.Addeds QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I cartiythat l have read thisapplicaHon and statelhatthe above information
O w is correct.I agree to comply with all city and county ordinances and dale laws 1 PERMITISSUANCE 12.a FEES PAID:
} 1 relating to Wilding construction,and hereby authorize repreadmatives.fthW
N cit to enterupon the above-mentiored propertyfor W ion purposes. ALTFRORADDTOMECH.
(- city
agree save,indemnify an d eeMess the f pertNo g•� Date Reecipt#
L) tBsju On,p .mi,m sand..panse,whith mayinanywayaccom AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:
a a nat d City 1 sequen of the gr' ting d this permit,
" AIR HANDLING UNIT(OVER 10,o00CFM) CONSTRUCTION TAX
HAUSC HOD(W/DlC1ignamrcoApp to CONSTRUCTION TAX PAID:
MATESURE 05
Will the applicant or future Wildin n smr .rhandle hound.., HEATINGUMT(TO100,"11711) Date Recei till
mmerelas defined by the Cu n. unicipal hapter9.lZ and the
I1ealth and Safety Cde S dion 75537(a)t HEATING UNIT(OVER 100,000 BTU TOTAL:
Yes , M No
Will the applicant orfumre building occupant use equipment or devices VEMILATION FAN(SINGLE RIESID) Lt,oa ISSUANCE DATE
which CMI ham Mous air contamiwnts as defined by the Bay Area Air tt"',F"1JIBsy,
. Ouailty Management District? BOILER-COMP OHP OR 100,00)BTU)
Yet ❑� Nmaterials 4h.vere.dthe haaarYo terialsrequirementsunder Chapter 6.95of BOILER-COMP(OVER I(I,000311]) u0v
the IIlomWlie.ithh fety Cde,Stet lops 25505,25533 and 75530.1
o
nthatifi 1 Ing does a currently have a tenant,that it W my NEW RESIDENTIAL MECH. SQ.FT. '1.nes' t occ!Pan of the coq erment,which must be rout a City (,s j`,1nnW"faAcc.1 a i i e a cy V `'a
r 4t Q tis �k K W--QP R fC ^oc� a W a
Ownerora.thodrad agent Date I,{rlx SSUED OY:
TOTAL: L L 1
OFFICE COPY