20246 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bntldiag Address: ( L c � 20246
6
a / VIteow, one: - , A A
Y CITY OF CUPERTINO-BUILDING DIVISION
Conaaanrs Name: S+ A;AJ/ bdNc.No: APPLICATION /PERMIT
ri ' BUILDINGELI)CTRICALPL(MBING-MECHAMCAL CATEGORY CONTROLM
Architect/Engineer: Lic.No:
/� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address ( �'
PFRMITISSUANCE V_X ❑
LICENSED CONTRunder SDECLARATION �/�,
I hereby
SactkInntht lam firessed Chapter9(e,and my
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ii with SI Mn7000)of DiWton3 oRheBminessand ProfestonsCode,andm
Ilcense Is In full(o dfttt. �"�j Q��//QQ P y PANELS � ^' ( 1
License Chss_ zlic.N___ 1 `�{— 4. Jd
Date Contractor 2011000 AMPS
ARCHITECTS DECLARATION
re0 7 I understand cryplanashag be used u public records OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
u�OSIGNSELFGTRICAL
Licensed Professional
<Qw OWNER-BUILDER DECLARATION
I-n FnSPECIAL CIRCUIT/MISC
IM1ercbya(OrmtFatlam exempt(romtM1e Cont ractori Licenselawfw the ,
OZH following reason.(Section 7031.5,Business and Professons Code:Any city or TEMPORPOL 1
P� courtywhich requiresa pernottocoratruct,alter,Improve,demolish,orrepalr
anystmMmpdortolbt ance,aL requb theappBrantforsuch permit to POWER CES
a f le a signed statement that he is licensed pursuant to the pronso ru of the
Ow Contractors License Law(Chapmr9(commencingwith Section 7000)ofCEO-
3 t e basis fo Butnessand Pro(mlamC Any
violation
of Seem 7M1.5 by any SWENMih L � VALUAO VC2
P y,'^I the bash far NS alleged exemption. Any violation of Section 7011.5 by any I E-al/ ( C( J'�Cf
<5
applicant furs permit subjectatheapplicanttoa civil penaltyo(mot monethan SETS Eq 4 ( s"lj •—
Q five hundred dollars($500. NEW REST
❑I,as owner of the property,or my employees with wages as their sole TR `"Q'FT' STORIES TYPE CONSTRUCTION
compensation,willelothe work and thestructure Is not Intended or offend for
5 D sale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RES.UNITS
0.0. who does such work hurnelforthtough his own employees,provided that such
Improevemids are not intended or offered for sale.If,however,the Ito llding or TOTAL:
improvement issold wlthinoneyearofcomplelogthe owner-budderwdlfuve
Iry..�+
LIrden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
S as owner of the property,am exclusively contracting with licensedPERMIT L�UANCE
contractors to coretmct the project(Sec.70th,Business and Profassims Code:
The Contractors License Law does net apply to an owner of property who
budds or Improves thereon,and who comom for such pi,ujeas with a ALTER-DRAIN&VENT-WATER(EA)S
c,naclor(s)Ilanxd pursuant to the Contractor's License Law. BACKFLOWPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reasonOUTSIDE FEES
Owner Date DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION ftECEBr
FDI
TURES- P SCHOOL TAX N
HI he. affirm that I have a certificate of consent to.11-Insure,or RECEIPT'N
certificate ofWorkers Compereatlonlwurance or a certified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLE IS PARK FEE Y N
3800,lab C.) RFLFJ[xI'X
Policy p GAEA.SYSI'FM-OVER d(FA) BUILDING DIVISION FEES
CoCany
5CSrtiBed copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF El(EMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20(1 Date Recd t#
(fhissealon need na becompleedIf the permit is fwone hundred dollars
(Etro)orlesa.) WATER HEATER W/VENT/FZECTR ENERGYFEE Y_ N_
I srrtifythat in the performance of the work for which this permit Is Issued,
1 shall not employ any P�y or an ecome hie t WATER SYSTEM/TREATING
Workers Compensation la. a PAID
OZ Applicant a NEW RESIDENTIAL PLMB. SQ.FT. Date RcceI t#
Z O NOTICETQARPtICANT: ,after king AfficateofExem nyou
should become subject to the Workers'Compereation provisions of the Labor tf1 TOTAL :
CCCO Coae,you must fort hwith comply with such prowbiom or this permit shall be BUILDING FEE L CC
W F3 deemed revoked.
O CONSTRUCTION LENDING AGENCY -�-s� SEISMIC FEE t
a Iherebyaffirmthat there b a corutroctlon lendingagency forthe perform Pte— ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.Q TOTAL _
V O sander's Name PLUMBING FEE
r Lenders Adaress QTY. MECHANICAL PERMIT FEE
w iscorIwdlfy(halt have read thbapplicatlunandatamthattheabove infer duo MECHANICAL FEE
act.l agree to comply with all mi city acounty ordina^cesa^d statelaws PERMIT ISSUANCE FEES PAID:
} IL relating rebuilding construction,and hereby authorize representatives of this
N city to enter upon the above-mrstioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Capetian Date Receipt#
V against liabilities,judgments,cote and expenses which may In any wayaccrue AIR HANDLING UNIT(T010,000 CFM) I SUBTOTAL:
against said City in coearyuence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING TWIT(OVER 10,(100 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(To IDQ000 BTU) Date ReceI tit
material as defined by the Cupertino Municipal Cods,Chapter 9.12,and the _
Fle❑althand Safety Cody,Ecctioon25532(a)7 HPATINGUMT(OVFR100,ODOBT(A TO•EAL`FAN
,- s
Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OEIPOR 100,000 BTW J
Yes No h�
have read the hazy a us materials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) City i O`r11PP.
the California Health&Safety Code,Sections 25505,75533 and 25534.1 la I (tj(I(p
understand that if the building does em currently have a tenant,that itis my NEW REDI=AL MECH. SOFT.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Ompamy. (�y�
Ownecoraurhorlud agent Date ISSUEDBY:V lJ
TOTAL:
OFFICE COPY