20819 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Adders: f")0('� �9I�I
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CS r� CITY OF CUPERTINO-BUILDING DIVISION A���� ,�G/1
Co rcrorName: /�J �Mae{�No: APPLICATION if PERMIT CV
(s�r a"-«' �«/ �•a'°-f BUILDING-ELECTRICAL-PLUMBINGMECIIANICAL CATEGORY CONTROL.
Architect/Engine Lic.N.
OTT ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: TRPERMITISSUANCE ❑ ❑ ❑ Y
LICENSED CONTRACTOR'S DECLARATION 1�
I hereomthatllicensed under provisions fChapter , APPLIANCES-RESIDENTIAL JOB DLSCRBON
ngwlth5ccfin700)ofDb,Wslon3oftheBusussandPrro(essionsCodeand
my
license la In hull fa d effect. PANELS
Date 4 hill
/-
Date Contractor 201-1000 AMPS e-v
ARCHITECT as RAT OVER1f100AMPS SQ.FT.FLOOR AREA $/SQ.FT.
��y ZO I understand my plan dull be used u public records
U�j Licensed Professional SIGNS ELECTRICAL
<a OWNER-BUILDER DECLARATION
SPECIAL CIIICNT/M1SC
L, 7 lheraf0rtnthallamexemptfromtheProfessions
License Lawforthe
followinggre (Section 7031.5,Business andd Pmtesabns Code:Any city orTEMPMEIPR ORPOLEINST.
cauntywhichrequi apermittommimo,alter,impmv demoltah,orrepalr
� G anyswctureprior to ns Uswane,alaorequireatheappBant forsuch perMrto POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
ciH
IPO Commerce.License Law(Chapter 9(commenng with Section 7000)of Dwi- gyy�(,`pNG POOL ELECTRIC
�30r sion 3oftheBusiness and ProfexionoCode)orthatheNexem therefromand VALUATION
kc Set 5 the basis for the alleged exemplbn. Any vlolation of Sectlin.7¢313 by any OUTLETS-SWITCHES-FIXTURESapplicant for a permit subject the applicant to a civil penalty a net more than
five hundred dollars($50(f. NEW RESIDENII ECTR SQ FT
..p, ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
C compensation,will clothe work and thestructure R not intended or offered for
q sale(Sec.704t Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who Wilds or improves thenars,and
t-$^ whodocssuchwarkhimsifeorthraugh hisownemployeea,provided that such OCC.GROUP RIS.UMTS
Improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement Wold withinoneyearofcomplet mtheowner-buWerwill have -'
t"idenof proving that he did nm build or improve for purpose ofmle.). QTY. PL PE FEE FLOOD ZONE APN
I_,f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANC
mntractorm to construct the project(Sec 7044,Busmen and Professions Code: r 11
TTm Contractor's License Law don not apply to an owner of property who AL -DRAIN T- TER
Wor improver thereon,and who contracts for such projects with a EN _
cstreets)licensed pursuant to the Contractor.License Law. BA W TEC C 151 am
I am exempt under Sec. season
B&P C for this
SANITARY Y_ N_
• Owner Date DRAIN ROO A RECEIT a
WORKMAN COMPENSATION DECLARATION FIXTRAIT SCHOOL TAX Y_ N_
I hereby affirm that 1 have a certificate of consent to self-Insure,ora RECEIPT 0
scare of Workers Compensationlnsurance ora certified copy thereof(Ree. GAS EA. STEM-1 IN O EI5 PARK FTE Y_ N
31�WYLNb C3 W4�7763JV RECEIPT
VE
Com anv 6 .q Il+ff/7 GAS EA.SYS[EM-0V ) BUILDING DIVISION FEES
ffCertiBed copy Is herebyyh nixed. GREASE/INDUSTRLWASTEBJTFRCEPTDR PLANCHECK FEE
OCedified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Retvi t#
(This section need not W completed if the permit Is for one hundred dollars
($10(fimless.) WATER HEATER W/VENT/ELFLTR ENERGY FEE Y_ N_
I certify that in the perfomu eeof the work for which this permit is Issued,
I shall not employ any person In any manner ro as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
0Z ApplicantNEW RFSIDPNTIAL PLMB. SQ.FT. Date Rewi t#
Z O NOTICE TO APPLICAM:ILaRer making this Certificatecef Exemption,you
Hy should become subject to the Workers-Compensation penublov of the Labor TOTAL:
CC Code,you rwsl forthwith comply with such prowiav orthla permirshallbe BUILDING FEE
Uj j deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Z C I hereby affirmthat there b amvtrudlon lendingagency forthe perform TOTAL: ELECTRIC FEE
7 ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
O O Lender's Name 7Y. MECHANICAL PERMIT FEE PLUMBING FEE
LL F Lender'..Address O MECHANICAL FEE ,
O l certlfythatl have read rheiappllationand stamthitiFabove Information
correct.i agreeto complywith all cityand county ordinances and sate laws P
0 V ctordinancesERMIT ISSUANCE S PAID:
1 relating to building construction,and hereby authorize representatives ofthis
h 0) city to enter upon the above oil ed pertyfor Napectionpurposes. ALMORADOTOMECH.
(We)agree to save,inclemently an p harmless;the City of Cupertino Date Receipt#
V
against ,jrdgments,coss expenses which may In anywayacvue AIR HANDLING UNIT(TO 10,000 CFM) T SUBTOTAL:
again y' the granting o(this permit.
AIR HANDLING UNIT(OVER IQ000CFM) CONSTRUCTION TAX
Stgrawre of Applicant Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appll.rd orfuturc building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Healrh and Safcty Ccde Section 25532(a)? HEA TING UNlT(OVER l00,(X0 BTU) TOTAL:
❑ Yc. r]No
Wlllthe applicant orfutumbuilding occupant useequipment ordevices VENTILATION FAN(SINGLE RESID) DATE
which endft hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP)IIP OR IWIXIO BTU)
YeaFF��No
I have mad the hmars`Feus materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) 11�
the California Health&Safety Code,Sections 25505,25533 and 25534.1 \iU 3O
understand that lithe building does not currently have.tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT
mineral bII tool fy the occupant of the requirements which must be met
prior to an of aCent to Occupancy. / � { W�L�4EWA41
7
Owner or authod ant Date � ISSUED OY:
70TAL:
OFFICE COPY