20813 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prised Identification Ou PEJLNITNO.
Building Address: 20813
ATE
iJw.ces CITY OF CUPERTINO-BUILDING DIVISION /1 O
• ontntor.Na : Lie.Nee APPLICATION / PERMIT —`I
ge BUILDINGELECTRICAGPLUMBINGMECH NlCAL CATEGORY CONTROL R
rc en/Engineer. Lid.No:
j� QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO
ress
Add : �aV • PFRhIITISSUANCE 1:1 Ela 11LICENSED CONTRACTOR'S DECLARATION �I
I hereby affirm that l am hemacd under provisions ofChapler 9(commmc APPLIANCESRESIDENRIAL JOB DESCRIVTION
ingwlth Secdon7000)of Divlslan3 ofthe Buslncessand ProfessionsCode,and my
license is In and effect PANELS
�LI.N�� PIN V l •–Y
Date 7777 Cmu act Ul!IQ 20 ANTS
ARCHITECI-S DECIAR TION 201-1000 AMT'S
ot02 I understand my plan shall be used a public record& OVER1000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
CO
U(/ Wmnxd Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION 6p, B —
Lo., } I hereby affirnthat l am exempt fromthe Contractor's License Lawforlhe
}O Z "q) following reason.(Section 7031.5,Busism and Professions Code:Any city or m '
I'�y countywhich requires a permit to construct,alter,Improve,demolish,oreepalr 'H'M 'MEI'Dt OR TOLE]NST.
Agyl g< anystmu mpriortoi Lwance,ataomquimatheappBcantfo...ch permit to
PO DEVICES �.
�i V file a signed statement that he 6 rlicensed(core pursuant it the proWlons f the
�3 G Con3o(theLicense Law(Chapter9(mmmenearg thathe hSection
mp"hemfm Dlvl- swIM aNGP0OLEL VALUATION
O
the
he the
aged exemption.Any
f exempt therefrom and - --
Syd the basis for the alleged exemption. Any violation of MuSection 78335 re any �E.��.rc
�s applldantfora permit civil penalty
ao d not nnrethan -'-��
five hundred dollars(SM. NEWRESIDENI'IALELECTR SQF7. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
�7a compensation,will do the work.and the structure Is not intended or offered for
O sale(Sec.70K Businessand Pretenders Code:The Contranors License Law
does not apply to an owner of property who builds or Improves thereon,and OCG GROUP RFS.I1NTi'S
c-$^ who does such work Mmselforthrough his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement Is sold within one yea rofeompletion,the owner-builder will have
t on of proving that he did not Wild or Improve for Purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LML as owner of the property,am exclusively contracting with licensed PFRMITISSUANCE 'ZsCV
contractors to construct the project(Sec.7044 Business and Professions Code:
The Contractors Llcerue Law does rat apply to an owner a property who
builds or Improves thereon,and who contracts for such p5ojects with a ALTER-DRAIN&VENT-WATER(EA)
rynl�due(.)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ BACK FLOW PROTECT.DEVICE
I am exempt under Sec B&P C for this reason aa)ts
Owner Date DRAINS FLOOR ROOF,AREA,COND. �t..s(/ SANITARY Y_ N_
• ft_ NR
WORIGNAN COMPENSATION DECLARATION FLY'IURES I'ER TRM SCI IDOL TAX Y_ N_
❑I hereby affirm that T have a certificate of consent to se141neure,or a RECEII'T M
3800,Uteo(Workers'Compevamnlnsuranee ora cetl(led copythereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy
lab CJ RECEIIT I
Polity M GAS EA.SYSIFM-0VER d(FA)
Com ,ray BUILDING DIVISION FEES
Ce BUILDING
GREASE/INDUSTRL WASTE INTERCEPTOR. PLANGHEGIC FEE
❑Certllied copy 6 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASEiRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.]AOFT. Date Repel HI
(Thissedion need not be completed Rthe permit a for ane hundred dollars
($100)or less.) WATER HEATER W/VENT/ELE-CTR x� ENERGYFEE Y_ N_
I certify that In the performanceOf the work forwNch this Permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYST[M/TREATING
Workers Compensation Laws of California.Date PAID
NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
O Z Applican`
Z O NOTICE TO APPLICANT.if,after making this Certificate of Exemption,you
should become sublet to the Worl cri Compensation provisions of the Labor TOTAL:
N Code,you at forthwith comply with such provisions orchis permit shall be BUILDING FEE
LU ] deemed revoked.
cONSTRUCriON LENDING AGENCY SEISMIC FEE
a Ihereby.firm that there Is a mvwtimn lending agency for the perform //'�k�'1 ELECTRIC FEE
M Z an"of the work for which this permit 6 Issued(Sec.3097,Civ.C.) TOTAL' Oleo
C-) O Loruirre Name PLUMBING FEE
I- I<nder.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W beet.I agreet c replyead is with
aand n and
thattheordina above dgateInformation
am
1 Ismrret.luildino complywlthaindhereb auntyoMinaneesand softws PERMIT ISSUANCE FEES PAID:
} city relatito
enteru ponge abnvtlon,andhemopentyorin representativespurposes.
W <ItyWenleree to eabovcmentioned Pro Peh for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnif d kenp harmless the City of Cupertino Date Reeeiptil
V against llabllltles,pdgments sets d,;Pr swhich nuy In anyway AIRHANDLING UNIT 10,1100 CFM) SUBTOTAL:
against old In ron ce the tingofthls e
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
p ant tractor ale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
alill'ApHAZARDOUS MATERIALS ISCLOSUR
Wllltheapplia occupant orfuture building opant store or handle lurardous HEATING UNIT(10 100,000 BTU) Date Recel tN
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
IIr.lth and Safety Code Section 75537(.)7 HEATING UNIT(OVER 100,000 RTU) - 0TAL: bsQf
Myna
MNO
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) I S�}PCE DATE
which emit havMous air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP(3HP OR 100,0(10 BTU) t , O G I�CIJ
4 Yes (}I to
ave read the bavaroNNo
hmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 10go00 BTU)
the Ca liforn la I lealth&Safety Code,Set Ions 25SOS,75533 and 75534.1 /a
It ndersta nd that if the bu ilding does not currently have a tenant,that It 6 my NEW RESIDENTIAL MECH. 9Q.Fr U'Jfy Of CuDel'fino
responsibility to notify the occupant of the requirements which must be met
prior to issuance of.Certificate of Occupancy.
Owner or authori,eed agent Date TOTAL: ISSUED BY: v_7r�1�[,J�-• <
OFFICE COPY