20177 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
°Yaig J dress:g 7 _ 20177
Chvner me: one:
P1 7 4 CITY OF CUPERTINO-BUILDING DIVISION A A
�tq�L7 tJ/�� �± APPLICATION /PERMIT �' � ?0
Contra I'Vrwc z 5'_o: N .
"I BU[LDING-ELECTItICA4PL[JM81NG-M[CHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lic,No:
QTY�; �'ECECTRIC PBRM[T 1 �PEL,;' -- BgII,DES10PERMITINFO- -
' Address: PERMIT ISSUANCE ] ,❑ ❑
LICENSED CONTRACTOR'S DECLARATION L'JJs
I hereby,affirm flat lam&enu d rp nsofcha ter9(rommene- APPLIANCES-RESIDENTIAL JOB DLSCRIPITON -
ingwitI I fun 7000)o(Dl affect dt s t ® nsCode;and my Pia�..///��� ���
liceneelaln full fo de((ect. PANELS C}.f-IH2Y
LI Cla LIc.B ' /
Date ContractorIT IQ 2QQ AMPS
ARCHITECT D CLARA 10 201-1000AMPS
q�q�vv a0 O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA, $/SQ.FT.
k (Oj Licensed Professional - SIGNS ELECTRICAL,
6 N OWNER-BUILDER DECLARATION 4LU��
UIT/MISC
t, Ihereby affirmlhit l am exempt from the Contractor's License law forthe
'Z O followingreason.(Section 7031.5,Business and Professions Code:An d or
roz µ9 r ORPOLEIN
countywhlchrequiresapermRtocowtrucyaliepimpmv denwllsh,orrepalr
a anystmclure pdortoits Issuance,also requireslheapplicant forsuch permit to
r V file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commencing with Section 7003)of Dod-
t,�Os elon3ofthe8usinessand PrafessbruCade)orthat hebexemptthere(romand 0 EC C VALUATION
Q the isatin for the alleged exemption. Any violation of Section 7Qi1.5 by any TC FI
applicant for a permit subjects the applicant to a civil penalty of not more than ( ly O
g five hundred dollars(5500).
q�^�n ❑I,as owner of the property,or my employees with wages as their sole L TYPE CONSTRUCTION
compensation,will do the work andthe structure is not intended or offered for
O sale(Sac.7044,Businessand Professions Code:The ContractorsLicense law
does nm apply to an owner of property who Wilds or improves thereon,andOCC.CROUP RFS.IIMTS
who doessuch work himself or through hisown employees,provided that suchImprovements are not Intended oroffered forage.If,howevegthe building orpL; -
improvement bsold withinoneyearofcompletion,lhe owner-bullderwill have
tFe oden of proving that he did not build or Improve for purpose of sale) Q'[y�.' %LNG PERMIT FEE FLOOp7ANE pPN
L L as Owner of the property,am exclusively contracting with Ilmnsed UANCE '
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
bu Ude or Improves thereon,and who contracts for such projects with a
cry�gBt(actor(a)hceved pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE. ,"FEE SUMMARY
,"t,am exempt under Sec. B k P C for thin reason
Date•
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECE1er a❑[hereby affirm,that I have a certificate of consent to self-Insure,ora FIXTURES PER TRAP SCHOOLTAX Y NRECEIPT M
certificate of Workers'CompewaHonlnsurarm or a certified ropy thereof(Sec. GAS�FA.SYSTEM-]INC.IOUTLETS PARK FEE Y N
3800,L.ab C.) '
Policy R RECEIPT B
Com aPy
GAS EA.SYSTEM-OVER 4(EA) - BUILDING DI VISION FEES
[FZified copy Is herebyfurnished.the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE _
!6_t�'C' ertlEed ropy Is tiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This section need not be completed](the permit b(Drone hundred dollars
(g1I°)arl th WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify thatlnthe person in
theworkso as to hthlspesubjrmit ebo theed, —
I shall not employ any person In any nunner m as to become subject to the '
Workeis'Compensatlon Laws of California.pale WATER SYSTEM/TREATING � PAID
z Z Applicant
Z O NOTICE TO APPLICANT:[!,after making this Certltlrate of Exemption,you NEW RESIDENTIAL PLMB. SQ}T, Date Recei t#
should become subject to the Workeri Compensation provisions of the Labor~ mTOTAL:N Code,you most forthwith comply with such provbloru or this permit shall be
W > deemed revoked. BUILDING 3
_
CL p CONSTRUCTION LENDING AdDvcy SEISMIC FEE
,
I hersbyafRrmthat there b a construction lending agency for the perform- ELECTRIC FEE
D 0 ance of the work for which this permit is bsued(Sec.3097,Civ.C.) TOTAL: -
O Lander.Name - - .. PLUMBING FEE
LL F- Lenders Address QTY.. -MECHANICALPERMIT•, MECHANICAL FEE
O W Icertltyrhatl have read thbapplicatlomnd state Post theaboveinformatlon
Iscorrect.Iagreetocompiywith a8 cityand countyordinancesand state laws PERMITIESUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this '
H Z
city toenter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date 'Reeei
— (We)agree to save,indemnify an d keep the e City of Cupertino P[#
against liabilities,jail nts,co98and expnten.whichmayinanywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
at s City to equence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Ignorant of Applicant/Contractor (O Data V EXHAUST HOOD(W/DUCT) CONSTRUCTION TAJ(PAID:
HAZARDOUS MATERIALS DISCLOSURE .
Willthe applicant or future building Occupant Store or handle hazardous HEATING UMT(TO 100,000 BTU) Date Recei [#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
He❑alt Yaannd Safety Codt�e�-�S4ectiion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant diruture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE which emit hazardous air wntamiwnts as defined by the Bay Area Air DATE
PAM p■ E E
. Quality Management District? BOILER-COMPOHPOR 100,000 BTU) PAID,
4 Yea o 1
haveread Healthe h
o�mode,Sections
and 2554. 1 of BOILER-COMP(OVER 100,000 BTU) JUN J. 5 IySJ
the Cali(ornla Health 4r Sot( Code,Sectiore 75505,25533 and 25534. 1 �
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MEIN. SQ.FT.
responsibility to notify occupant of the requirements which must be out
a c - 4t .{�
p " eofa I,RateofOcmpgnry. City of Caperhno
Owner or authorlved agent Data ISSUEDBY:
TOTAL:
OFFICE COPY