20439 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Pr9'cn ldennf(aaon PERMIT NO.
o , Building Addrcaa:
20439
) 5-
ners assn: on .
GCITY OF CUPERTINO-BUILDING DIVISION ��1 r•I O
c=sit Lk.No: APPLICATION /PERMIT — l
J G BURRING-ELECTRICAI PLUMBINGMFGHANICAL CATEGORY CONTROL 4
Architect/Engineer. Lie Na:
Q'n. ELECTRICPERMIT FE,aEe,eyy�s BUILDING PERMIT INFO
Address: PFRNI TISSUANCE W
LICENSED CONTRACTOR'S DECLARATION
Iherebyalfireathat l amlicensed under provlslonsof Chapter9(commenc APPLIANCE -RESIDEN I, JOB ESC ON
Ingwlth Sedion7000)of DiWMw3ofthe Buslnessand Profeslons Code,and my _
license binfull force and d(ect. PANUS fz^ \ _ `VGA
License Class Cere C� V`V� l.�
Data Contactor
ARCHITEe usedDECLARATION OVERI0 AMPS
�7 I understand my plan shall be used ss public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ,FT.
O
Q ELicensed professional SIGNS ELECTRICAL
+1 OWNEReBUILDER DECLARATION
I-n t,7 SI'ECIALCR2CUIT/MISC
owing rasoren that n.(Sedlam31.5,Bxempt lromthe Contractor' Code:imnse Law fort he L43 I
following hmqu( capeion 11.5,Business and Professionsimpaemlbhnydtyor TEMP METER OR POLE[NST.
F countywhkh rcqulresa permittocovtmct,alter improve,demoilh,orrepalr
<� any atronure prlstatement
fiesthat
he It also sed pursuantreathe t the fro ucla inionsofpermit e
a�� ❑L a signed statement that he L licensed pursuant to the provisions of the MOWER DEVICES
Owl Contraaore License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
Vt ska3ofthe Nudneaand l'mfessiom CodOmthat helexem therefromanf - ^ VALUATION
,'�'„Q$ the basis for the alleged exemption. Any violation of Scetion 70315 by any O(pIT,ETSSWITCHESFlXTIIRES
e,6! ppNcentfora peroutsubjenetheappllcamm.civil penakyofnetn
orethan
(((�����,,,I��'�++ndred doll.rs(5500). SQ.FT. STORIES TYKE CONSTRUCTION
as owner o(the property,or my employee with wages as their sok NEW RESIDGN7IAL ELFGTR
c cope satlon,will dothe work,and thestructure L not Intended or offered for
ple(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
who doessuch work hlmselforthrough hlsownemployces,provided that such lY'
improvements an not Intended oroffercd for sale.If,however,the building or TOTAL:
Improvement Lsold within oneyearofcompletion,the owmr-W ilderwlll have
t"relen of proving that he didnot Wild or improve for purpose ofsele.). QTY. PLUMBING PERMIT 'FEE FLOOD LONE APN
u 4 as..or of the property,am exclusively cant—ung with Incensed PFRMIT ISSUANCE �T
contractors to construct the project(See.7044,Business and Professions Code: 12,G
The Contactor.License Maw does not apply to an owner of property who ALTER-DRAIN&VENT'-WATER(EAl
Wilds or Improves thereon, and who contracts for such p(ojern with a x FEE SUMMARY
cq➢!(+ctoras
W licensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE
u I em exempt under See. B k P C for this reon
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY RECEB'f M
WORKMAN COMPENSATION DECLARATION p1XT[IRES,PER•(.RAI' aa� SCHOOL TAX Y_ N_
❑I hereby affirm that I have.certificate of consent to self-maure,ora Ls 4 RECEIPTM
rerti(Icab C.)teofWorkers'Compensationlmumnmoramnl(led ropythereof(Sec.
3X00,MaGAS EA.SYSTEM-I INCA 0UTLETS PARK IEE Y N_
RECER'T x
Policy M GAS EA.SYSTEM-OVER 4(EA)
Com any NCKFECDI VISION FEES
Coddled copy L herebyfurnished.the
city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertlRed copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-SNRM EA.200PT. Date RCCCI t#Sr.,7Q
(fhb section need not be completed If the permit L for ane hundred dollars
(8100)orless3 WATER HEATER W/VENT/E.DCTR ENERGY FEE Y_ N_
I certify that In the pedomnance o(the wmklorwhlch this permit b Loved,
I shaB eat employ any person In any runner so as to became subject to the WATER SYSIEM/TRFATING
Worker;Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL I'LMB, SQFT. Date Recel t#
T:R
Z O NOTICE TO APFLICAN ,after making this Certificate of Exemption,you
should became subject to the Workers'Compensation provisions ofthe Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be B `
W > deemed revoked.
CONSTRUCTION LENDINGAGENCY SEISMIC FEE
a IhercbyafBrm that there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE ( QQ
Z ance ofthe work for which this permit L Issued&r.3097,Civ.C.)
U O Lender's Name PLUMBING FEE v�
1- Lenders address - QTY. ,MECHANICAL PERMIT FEB
LL U IceAifyth.tl have readthisappilcatiorand amtethat thvabove information ^ MECHANICAL FEE
O W iscorrect.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE 11�IZ FEES PAID:
r IL relating to building construction,and hereby authorlu representatives ofthl
(— N chytoenterupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MRCH. k
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recel t#
U agaWu[Babllities,judgments,costs and expense which may in anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
_
tsaldC I�nngryence fPtFeaning d this permit. AIR HANDLING UNIT(OVER IO,000 CFM) CONSTRUCTION TAX
Sgratum of Applica t/fCC.rtaetnr Date EXHAUST 1IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO IOD,ODO BTI) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Healthand Sdriy Code Section25532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL: s
fI Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION 17AN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DistHet7 BOILER-COMP Of IPOR 100,000 BTI)
4yes n❑No __
haveread the hazarRusmaterials requirements under Chapter 6.95of BOILER-COMP(OVOt100,000BTU) b/E�p{
the California Health&Safety Code,Semens 75505,25533aad 25534.1 PFA
understand that lithe building does not currently have.tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met
priortoWuanceofa CenifirateofOmpancy.
v
"4
Owner or authorlud agent - Date. CO ISSUED BY:
TOTAL:
OFFICE COPY