20463 ,APPLICANT TO FILL IN INFORMATION WITHIN KEIJ LINLo - i- .
Building Project Identification PERMIT NO.
Building Address: 20463
146-1-r N� 7_963 �sdN Avg`
-Owner's arae: hone: APPLICATION BMI ADATE
A R A5dTAj ,Z cF j iZ�%/ CITY OF CUPERTINO-BUILDING DIVISION cc��
contractor'SName: f Lic.No: APPLICATION / PERMIT 7— jd_ /0
L1i 2 {_ty% C � CATEGORY CONTROL#
BUILDI NGELECTRICAL-PLUMBING-MECHANICAL
Arch i ct/Engineer: Lic.No:
/0CY_rF :%, .3
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 5kRhT0C SLt 1 U 4Q_ RD, PERMITISSUANCE
LICENSED CONTRACTOR'S DEC RATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRUMON
i ng with Section 7000)of Division 3 of the Business and Professions Code,and my
license is in full force and effect. PANELS
License Class C-3(,. Lic.# -
Date r/�Xy�y0 Contractor (/ylUP TO 200 AMPS7 v� t/� j r"'
ARCHITECTS DON 201-1000 AMPS G
O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA I $ SQ.FT.
00H
Z U Licensed Professional SIGNS ELECTRICAL
H C, OWNER-BUILDER DECLARATION
cn U) SPECIAL CIRCUIT/M j v
F., z I hereby affirm that I am exempt from the Contractor's License Law(or the
O Z following reason.(Section 7031.5,Business and Professions Code:Any city or i
county which requires a permit to construct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
U any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
sion 3 of the Business and Professions Code)orthat he is exempt therefrom and v
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES C)
applicant for a permit subjects the applicant to a civil penalty of not more than L
o O five hundred dollars($500). `SQ F1
Z
¢ ❑I,as owner of the property,or my employees with wages as their sole
NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for
Q 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
who does suchwork himself orthrough his own employees,provided that such
OCC.GROUP RES.UNITS
improvements are not intended oroffered for sale.If,however,thebuilding or TOTAL:
improvement issold within one year ofcompletion,the owner-builderwill have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD 7ANE APN
❑L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such projects with a — FEE SUMMARY
contractor(s)licensed pursuant to the Contractors License Law. gp FLOW PROTECT.DEVICE
❑I am exempt under Sec. B&P C for this reasonOUTSIDE
DRAINS-FLOOD,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION ] PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-insure,ora (� FIXTURES z C� RECEIPT q
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS-EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C J RECEIPT#
CENanyPolicy# GAS-EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars SEINER-SANITARY-STORM EA.200FT. Date Recel t#
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ FI. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
(1) Code,you must forthwith comply with such provisions or this permit shall be
5 y P y P P deemed revoked. BUILDING FEE
W —
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this ermit is issued(Sec.3097,Civ.C.)
Q 0 Lender's Name �V e�t�'�' PLUMBING FEE 'Ci
U. F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
IcertifythatIhavereadthisapplicationandstatethattheaboveinformation
O W
4. is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z_ Date Recei t#
(We)agree to save,indemnify an d keep harmless the City of Cupertino P
V against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in c sequence of the granting of this permit. CONSTRUCTION TAX
.04-, AIR- AIR HANDLING UNIT(OVER 10,000CFM)! /7X - 17-_ ��
t-
(J `� / ,
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 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: alt
❑Yes ��j No
Will the applicant 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 Dis ct? BOILER-COMP(3HP OR 100,000 BTU)
❑Yes I No
I have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of,a.Ce '*ate of Occupancy.
i
Owner or authorized agent Date TOTAL: ISSUED BYE✓(''-
OFFICE COPY