20219 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Ba1111ng Address: \� I111h
(/,,ante: \ .one:
PERMIT NO.
20219
(_\.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMITacsa
BUILDINC-ELMMCAL-PLUMBINGMECHANICAL
A
C Tactor'sName: 0,m
CATEGORY
CONTROLB
Architeel/Engl.r. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: if O
❑ 1:1❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 (comment,
Ingwith Section 7000)of Dlvlalon3ofthe Buslnessand ProfessioneCode, and my
I* is In fulfo and affect.
License ClamDat p}_{aComutd 1
APPLIANCES-RFSIDENTIAL
JOB DESCRIPTION
�,'� _ I
�('J� � �J.1 Com(
PANELS
UP TO 200ANIPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
1201.1000AMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA
E/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
ST'ECALCIRCUIT/M
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cmunic or's License Law for the
TEMP. M= OIJURINST.
following reason.(Sectlon 70315, Businemand Professions Code: Any city or
mentywhich requhesa permit to com uct, alter, Improve, denmlhh,orrepalr
anystrudure priorto its haance,alwrequlresthe applicantforsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor'sLicense Law (Cha pter9(commncing with Section 7000) of Divi-
sion 3 olthe Business and ProfemkmCede) arthat he h exempt therefrom and
POWER DEVI
SWIMMING POOL ELECTRIC
VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjecia the applicant to a civil penalty of nat more than
OUTLETSSWITCHFSn ES
NEW RESIDENnAl L SQFr.
(Iva hundred dollars MM.
I, as owner of the property, or my employees with wages as their wk
STORIES
TYPE CONSTRUCTION
-
compereatlan, will do the wor"ed the structure In not Intended or offered for
ak &c. 7644, Buebmse and PrMemlaro Cade: The Contractors License Taw
don not apply to an owner of property who Wilds or improves thereon, and
don such work himmUorthrough blame. employees, provided that such
OCC. GROUT'
RIS. UNITS
Improvements are not intended oraffered for sale. If,howevegthebuilding or
Improvement &sold withinoneyearofcomplelion,the owner-bullderwill have
TOTAL:
tl�,-soden of proving that he did em build or Improve for purpose ofsakJ.
I I L as owner of the property, am exclusively contracting with limned
contractors to construct the project (See 7014, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
PERMITISSUANCE
/a ,
FLOOD ZONE
APN
The Contractor's License Law does not apply to an owner of property who
bu Ods or Improves thereon, and who comracis for such pRojecia with a
cga4.dcr(e) limned pursuant to the Contractors License Law.
LII am exempt under Sec B & P C for this reason
ALTER -DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT' p
Owner Date
M
WORKAN COMPENSATION DECLARATION
C31 hereby affirm that I have a certificate of consent to self -Insure, ora
ourificateofWarken'Comperustlanlrsunnm.r. certlfkd xpylhereof(Sec'
3800, Lab CJ
17%n)RFS PER TRAP
SCI IDOL TAX Y N_
RECEIPT N
CAS PA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
Polley p
RECEIPT M
GAS F.A. SYSTEM -OVER 4 (RA)
Com any
BUILDING DI VISION FEES
[PCertifkd copy is herebytd.
�Cenlfled ropy is filed withh the the city inspection division.
CREASE/INDUSIRL WASTE 94TMCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
R) need not M completed tithe permit h farorm hundred dollars
PAID '
Date RC i tin
SEWER -SANITARY -STORM EA. 2WFT.
m lcmion
(S10 mmlem.)
permit is issued,
I snot employ
In oy he ary person
so as to become
I. eofthe any
I shall not employ any person In any manner se u to become subject to the
Workers' Compensation IJws of mia
Callfo. Data
ENERGY FEE Y N
—
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certitlate of Exemption, you
should become subject to the Worken'Compersation provisions of the Lshot
Date Remi of
NEWRESIDEKMALPLMB. SQFT.
TOTAL:
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyaffrrmthat there iso construction lendingagency forthe perform-
ante of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
I.rnder'e Name
TOTAL,
ELECTRIC FEE
PLUMBING FEE
L�
Lenders Addrea.
I mdlfythatl have readthb application and aatethatthe above Information
Is correct. l agree to comply with all city and county ordinances and Yate laws
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
MECHANICAL FEE
FEES PAID:
relating to building construction, and hereby authodae representatives of this
city to enter upon the abovementloned property for Inspection purposes.
(We) agree to eve, Indemnify and keep harmless the City y Cupertino
which may Inanywayaccme
against B mid
against Bald City In consequence o! the granting of this pertnil.
Inequence and of
ALTER OR ADD TO MECH.
Date Recei ted
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT rovF2R lo,000cl;Mi
CONSTRUCTION TAX
Signature of Appllmnt/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
HEATING UMT(TO 100,00 BTU)
Will the applies est or future building occupant store or he rad le haeardoue
material as defined by the Cupertino Munldpa l Code, Chapter 9.1 2, and the
Date Recei tit
HEATING UNIT (OVER 100,000 BTU)
•TOTAL:
He❑alt Yannd Safety Cade, Section 25532(e)7
No
VENTILATION FAN (SINGLE RFSID)
ISSUAVgF
Will the applicant or❑future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP OHI' OR 100,000 BTU)
QjjaIfty Management District?
Y. ONo
Ty J 1n, CSJ
BOILER-COMP(OVER100,000 BPR))
have read the haaadoua materials requirenumbe under Chapter 6.95 of
J, n H
the California Health & Safety Code, Sections 25505, 25533 and 25534. 1
NEW RESIDENTIAL MECH. SQ.FT
understand that if the building don not currently have a tenant, that It is my
responsibility to notify the occupant of the requirements which must be met
CvitV of (,'In IRO
rortoissuanc acertifiateof cvFancy.
I��
I/[L' Q
DaDate
��•�t �/� �. y�
Owner r authorised agent 113
TOTAL: 19
ISSUED BY:
OFFICE COPY