20508APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Project Identification. ' -
Building Address: L
PERMITNO.
20508,
nes one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT-��
BUIIOING-ELBCTRICALPLUMBING-MECHAMCAL
A A
°n atlora ase: L .N°:
CX c!&
A deet/ glnecr. Lk. No:
CATEGORY
CONTROL X
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: —
POWTISSUAN
❑ ❑ El
CONTRACTOR'S DECLARATION
IMrebyaffirmthatlam Bcensedunderpr isionsof Chapter9(commute
ingwith Se on7000)of DiAsion3ofthe Businessand PmfessloosCode, and my
i is In full f and effect.
lice lass LIc X y 2 Z 2/ d
L
Date - Contaac!A �%N !�
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby of 1. that Tam exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit toconstmn, alter, Improve, demolish,orrepalr
anystructure prior to its LssuancG also rayulresthe applicant for such permit to
file a signed statement that M is licensed pursuant to the provisions of the
Contractor's License law (Chapter 9 (commencing with Section 7000)o(gvi-
ston3 of the Business and Profeashms Code) or that he b exempt thercfromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjectsthe applicant to a civil penalty of not morethan
five hundred dollars ($500).
❑ L as owner of the property, or my employees with wages as their sole
ompensation, will do the work and the structure is not Intended or offered for
sale (Sec 7044, Business and professions Code: The Contractors Douse Law
does not apply to an owner of property who Wilds or improves thereon, and
whodoessuch work himself orthrough hisown employees, provided thatsuch
improvements are not Intended oroffered for sale. lIhowevegthebuildingor
improvement lssold within one yearofcompleBon, the owner-bullderwill have
th�e +rden of proving that he did not build or Improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with Mensed
contractors to construct the project (Sec. 7044, Business and Profeselons Code:
Tie Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such projects with a
,, �tt[[actor(s)It...d pursuant to the Contractor's License Law.
fJ I am exempt under Sec B & P C for this reason
APPLIANCES D L
JOB DFSCRIITION
PANELS
'
IDI-1000A.NPS
OVER 1000 AM
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGN
=1A /M
TIMP.MIWORPOLEINA
POWER DEl7
gWAtMINC ]A"]O EC-
C
VALUATION
q�
(O (DO /C�� I �1
OUTLETSSWITCIiESFIXTN2E5
-
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
-
OCC.GROUIs
ffR
- TOTAL:
QTY. PLUMBING PERMIT FEE-
FLOOD ZONE
PERMIT ISSUANCE
ALTER -DRAIN & VENT -WATER (EA)
'FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR, ROOF, AREA, COND.
FiXIII&6"`PER TRP
SANITARY V N_
RECEIPT X
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a rertificate of consent to self -Insure, or a
renifiene of Workeri Comw
pertlonInsurance or a certlfkd copythereof (Sec.
3g00,Lab C.)
Policy Y
SCHOOL TAX Y_ N_
RECEIPT X
GA S EA. SYSITM-1 NC.4OUTLETS
PARK FFP Y_ N
RECEIPT X
GAS EA. SYSTEM -OVER 4 (FA)
Cum
BUILDING DIVISION FEES
Certified copy b heed with t ecity -
�IPenif ed ropy b /i4d with the tlty inspection division.
�F CERTIFICATE OF EXEMPTION FROM WORKERS'.
COMPENSATION INSURANCE
Tfhlswetion need nu W completed lithe permit V forone hundred dollars
($100) or less.)
that
I certifylthat In the performance ofthe work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the
Workers Compensation Iawsof Califom^ .Date
Applicant
GREASE/BYDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei t#
.
CSE TRAP
SEWER-SANTTARY-STORM EA 200FT
WATFRHFATERW/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Recel t#
WATER SYSTEM/T'REikUN
NEWRESIDENTIALPLMB. SQF7.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
shots become eubjed tothe Workemi CampensaUon provblov orthe Labor
Cade, you most forthwith comply with such provtslora orchis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iberebyarfirm thattheretsamestruction lending agency for the perform-
race of the work for which this permit is issued (Sec. 309], Gv. Q
I.ender's Nacre
Lenders Address
• Icekifythatlhavereadthisapplicitlonand sate that the above information
rmrt. l agmeto complywlth all cityand county ordinances and statelaws
relating to building construction, and hereby authonoo representatives of this
city to enter upon the above-mcntloncd property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of C. Fenton
against liabilit jsdgme ,cassand eapenxs which may In anywayattme
ago iostsaid t inro ftM granting&thls permit.
2 � y
TOTAL:
BUILDING FEE
'
SEISMIC FEE
TOTAL:
ELECTRIC FEE
PLUMBINGFEE
QTY. MECHANICAL PERMIT ITE
MECHANICAL FEB
-
PERMIT ISSUANCE -
FEES PAID:
'.
ALTERORADDIOMECH.
Date Receipt#
AIR HANDLING UNIT CFO 10,000 CFM)
SUBTOTAL:
AIRHANDLiNGUNTT(OVER10,000CHd)
CONSTRUCTION TAX
sigr.ato AppTcant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant orfutumbuilding occupant store or handle ha andous
material as defined by the Cupertino Municipal Coda Chapter 9.12, and the
Healthand Sifcty Code Sectlon2S532(a)?
❑ Yes• r] No
Willthe applicant or Future building occupant meequlpmnt ordevUes
which emit havrdous air contaMmnb as dented by the Bay Area Air
Quality Management District?
Yes No
have read the Fara o materials requirements under Chapter 6.95 of
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
responsito notify the of the requirements which most be, met
priortoiss/"y/�/�� ofa teofOmpanry.
//// 1 / b/' —/V
F USTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATINGUMT CFO 100,000 BTU)
Date Recel t#
-
HEATNG UNIT (OVER 100,000 BTU)
TOTAL:
e
VENTILATION FAN (SINGLE REBID)
PAMEDATE
�: �� Q 199Q
as�p
p; cum=
Ll Hbility
t%"J
ISSUED BY:�1 U(�MWY-•O-a�-w'C
BOrLFR-COMP QHPOR 100,0(0 BTU)
BOILER-COMp(OVFR100,000BN)
NEW RESIDENTIALMECH. SQ.FT.
authorired Igent Date
TOTAL