20962 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identifi a n PERMIT NO.
Budamg Aearcas: 6T - G 20.962
—1 IC7one: A A
amp Y_ /i_rj-yy�.�/p LDAIL
CITY OF CUPERTINO-BUILDING DIVISION q 3/ FO
Contractors ante: Lic•No: APPLICATION /PERMIT O
BMLDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL X
Architect/Engineer. Lk.Nix
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Hl El-ECI PLUMB MI�H
Address PERMITISSUANCE �_d ❑ / ❑ ❑
LICENSED CONTRAROR'S DECLARATION
IMrcectionnnthatlam Bceneedhe Bustrovand Pro Cssions9de,and c MPUANCFSRESIDENTUL JOB DFSCRB'f10N
inerse I,ectlon 7000 iteffect. ofthe Buslnmand Pio/mlonaCode,andm
license b In full force and effect. PANELS /
License C6n Lic.p
Date Contractor
ARCHITECPS DECLARATION 2m-t000AMPS
p'!.
d O I understand my plavehall beued sas pubherecords OVERIOOOAMPS SQ.F7.FLOOR AREA E/SQ.FT.
SIGNS ELECTRICAL
r U ELirenscd Protey,lowl
a 6 w OWNER-BUILDER DECLARATION
EllSPFfIALCD2CNT/hi15C
Iherebyalflrmthatlam exempt from the Contractor's License law for the
OF following revon.(SnTlon 70313,Business and Professions Code:Any dty or TEMP,METER OR POLEINST.
county which requiresa permit mcom6ud,alter,improve,demolish,orrepair
anystructure priortolts Wsuancga6o recimmittheappliont forsuch permit to Yd ]'OWER DEVICES 0 file a signed statement that he 6 licensed pursuant to the prowdom of the
3w Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O sion3ofthe BuAnms nd Profmiom Cob
de)orthatheewmptthemfmmand
S e aVALUATION
t4 Sn the basis far the exemption.iAny violation o
lati !Section 7031.5 by any
¢ OUTLETS-SWITCHES FIXTURES
applicant fora permit subjects the applicant to a dull penalty of not mom than
five hundred dollars(S500). NEW RESIDENTIAL ELECTR SQ.IT. STORIES TYPE CONSTRUCTION
1.7Q^ nI,as owner of the property,or my employees with wages as their sole
compensation,wlldothe work and lhestrumum 6 not intended or offered for
y�o sale(Sec.7004,Buslnosand Profmlors Code:TM1e Contndors Llcenu law
$ don not apply loan owner of pmperty who Wilda orlmprovesthereon,and
$^ whodoessuchwork himself orthrough hisownemployms,provided that such OCC.GROW RES.UNITS
Improvements are not intended oroffered for sale.if howevcp the W ilding er TOTAL:
Improvement 6widwithing at he did et Wild
to peo eforpurpose
rposof inhave
th rden worn of the p he property,
a bund orvely=trading with l cense QTy. PLUMBING PERMIT FEE F7pOD 7DN8 MN
jrofT�w{,`ac as owner of the pmpeny,am exclusively essanwith licensed PERMITISSUANCE
radontomretmmtheproject not
Business and of(mors Code:
Cror Impr'o es,the Lew don not apply to t f owner of property who ALTER-DRAIN&VENT-WATER(EAI
Wilds to Improvn thereon, tc w contracts for ouch piojecv wuM1 a FEE SUMMARY
��'t..((1 ameBrensed pursuant tot rntradori License Law. BACK FLOW PROTECT.DEVICE OUTS I DE FEES
�I am ea unci B &P C for th reason
DRAINSFLOOK ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date re or a RECEBT p
WOR Ah COMPENSATION DECLARATION pp(•NRFS-1'FR TRAP $CI{OOL TAX Y N
I here rn that I have a certificate of consent to self-inm RECplI'T X
certifiateo(Workers'Comperson nImumnmaraanifiedmpythen f(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT p
Policy X GAS EA.SYSTEM-OVER 4(EAI
Com any BUILDING DIVISION FEES
�Certlfied copy 6 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR I'LANCHECK FEE
Certified ropy 6 filed with the city inspection division.
CERTIFICATE OF D(EIPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2MFT Date ReCel (#
QM1issedlon need our Ix,completed if the permit 6 furore hundred dollars
(SIM)orlm.) WATFRIIEATER W/VENT/ELECTR ENERGY FEE Y_ N
ceN _
I rtifythat the permare o
fornf the work for which this permit Is Word,
1 shall not employ any person in any manner on as to became subject to the WATER SYSTEM/TREATING
Workers'Ciun,m okm laws of Califom6. Date PAID-
0
AIDO Z NOTIAppliCE NEWRFSIDENIM,PIMB. SQ.F. Date Rewi t#
Z O NOTICE TO MPLICANT:$after moving this Ccrtltlate o(Eaemptbn,you
shruld become enbjsd to the Workers'Crmpewtirn pmvisiav of the Labor TOTAL:
F fD
Cade,you must forthwith comply with such provbiors orthis permit shall be
W j deemed revoked. BUILDING '
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
aI hereby affirm that them 6aconstruction lending agency for the perform TOTAL: ELECTRIC FEE p�
O LeM Z ance of the work for which this permit 6 Wseed(Sec.3097,Civ,C.)
Oder.Name PLUMBING FEE
LL F Lenders Aadmma, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I ceNifythat l haw mad this application and ctatethatthe above information
d bcorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authrmize representatives of this
F N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against habil ,jadgmentscoctsand expe which may in anyway.ccom AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL:
against ity mnseque of th ming of tM1le permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
/ CONSTRUCTION TAX PAID:
gnaw o(Appllant/ radon ace IXHAl15'T HOOD(W/DIX:T)
H DOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle hazardous HEATING UNIT(TO IDQ000 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 937,and the -
IleanhandSafety Gose Section 25532(a)7 HEATING UNIT(OVER{oB,BBM STU) TOTAL: - 0
❑Yes In No �—
Willtheappliantorfutum building occupant use equipment or devices VFNIIATION FAN(SINGLE RESID) �� �� 1��ATE
which emit hazardous air contaminants as defined by the Bay Area Air" 9
Quality Mawgcnrnt District? BOILER-COMP OHP OR 100,000 BTL!)
'?have Yn No 199
read the hsar us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 1 Ism✓
the California Health&Safety Code,Section 75505,25533 and 25534. 1 � (�
understand that if the Wn m
building donot currently have a los6 t,that It my NEW RESIDENTIAL MECH. SQ.R. ill aa(
responsibility to notify the occupant of the requirements which most be met ally,W 10UP N
prlortosuanceofa CedtfkateofOmupancy. \' V Twa1���a�a���
Owner or authorbed agent Date ISSUriDA �`���V
TOTAL:
OFFICE COPY