20808 APPLICANT N INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruildln, tiication PERMITNO.
Bu)IdiSAddress: 20808
�0 n O(�
X0413 L— LFy, PLACE- G �8 18
pera ame: - one: A A A
nil p, L[ 5. P12(��Qa' CITY OF CUPERTINO-BUILDING DIVISION
ContraaeraName: � w Lie No: APPLICATION /PERMIT L[
�/ IZCC 3V-tI BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL"
Amhited/Engineer - Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addxsxc,87 C IAjT POMTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Iry
I hereby affirm that l am licensed under provisions of Chapler9(commene- APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
,ngwilhSection 7000)ofMi sion3oftheBus,nessandPmfessionsCode,and my
It...c is in force and died, PANELS
L
Licensns e Class
Date CControntr
actor -1M IQ 200 AWS
ARCHITECT'S DECLARATION 2OTI000 AMP"' - l
02 I understand my plavaluRbe used as pubecrecvrds. OVER1000AMPS SQ.FT. OORAREA S/SQ.
Iv
O�j Licensed Professional SIGNS ELECTRICAL It
,LJ
< OWNER-BUILDER DECLARATION SPECIAL CIl2CUIT/MV.
-
,s. Z Iherebyasonthatlam exemptfrom the Contractor.License Law for the
oo following reason..(Semon 7(315,Business and Professions Code:Any city or
TEMP.METER OR POLE I
countywhich requires"permit eroo truct,requialter, apmvent for
such
permit
to
q ."'ti anystructure priori.its L+suance,alao requlrestheapplicant(or such permino POWER DEVI .S
E O a U file a signed statement that he is licensed pursuant to the provision"of the
�aw� Contractor'"LiccnseLaw(Chapter9(mmmencngwithSection 7000).1Dw,- SWIMMING ELE C VALUATION
F�O1 slon3.fthe Business and iProfcssionsCde)orthat he Jaexempt therefromand
Y.' the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITC
<s applicant!.ra permit subjects the applicant to a civil penalty ofnot morelhan
c. Ree hundred delta.(ASO%.
�y I as owner of theproperty, NEW RISIDENTIA LECIR SQ STORIES TYPECON•MUCTION
Q 7 ❑, ork,a or he employees with wage as there sole
le Ccompensation,.7wllldothework fe.l. swctureh not intended oriofferedfor
O sale(Sec.apply
Business and Pre perry Code:The Contractors License Law
docs not esuch torn owner ofpropertywhen emorlmproovidedthatn,ca thereon,and uch OCCGROUP RFS.UNITS
who Improvements
an k himself nded orough his own employees,provided ilding or
Improvementsarcno(intended earotco plsale.If,however, deer ill have TOTAL:Improvementburdenof usold within oneyhe did rofbuild or
the a for Pur Tose of sahave
tf<,kurd s o neerprovingof t to property,
a eXChu improve for purpose aces.). QTY. PLUMBING PERMIT FEE Igppp ppNg Aper
Lt"I,as owner tr the property, Se.70K Buselyiness
conuess andingd Pro est licensed
contmcto.to conswctthe project(Sec.706q euslne.aM Professbm Cde: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of pmperty who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pSojects with a FEE SUMMARY
cgE.tjaet (a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L�I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIT/
WORKMAN
mthat COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm the I have o certificate of consent to opythereo ora RECEIPT N
M01),Lab C.Workns'CompensaHonlnsuranmora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3300,lab C.)
Paley a RECEIPT"GAS EA.SYSTEM-OVER 6(EA) BUILDING DIVISION FEE
ny
Certffiedmpy Jaffledwhereby fum(shed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CrnBid copy V filed with the sty insped,on division.
CERTIFICATE OF INEMPI'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissection need not becompleled ifthepermit isloronehundrcddollars SEWER-SAMTARY-STORM EA.20OFT, Date Recei t#
($100)orless.) WATER HEATER W/VFIJT/ELECTR ENERGYFEE Y_ N_
1 cenifythat N the performance of the work for which this permit Is Laved,
I shall not employ any present in any manner so as to become subject to the WATER SYSTEM/TREATIN'C
Workers Compensation Laws of Cali(ernta.Date PAID
O Z NOTICE
Applicant NEW RESIDENTIAL PLMB. SQ.PT. Date Recei t#
Z O N'OTICETOAPPLICt I.theaRerrramngthJa ation pro is Exempt eL.W
should become subject to the Workers'Comperasatlan provisions of the Labor TOTAL:
Code,you must forthwith comply with such provlslons orth,s permit shall be
W~ CO BUILDING FEE —D
j deemed revoked. _
CL -CONSTRUCTION LENDING ACCNCY - SEISMIC FEE t
Iherebyaf8rm that them Is.construction lending agency for the perform- ELECTRIC ELECTRIC FEE
Z ante ofthe work for which this permit is issued!(Sm 3097,Civ.C.)
U O tenders Name - - PLUMBING FEE
LL F Lcodcrs Address - QTY. MECHANICAL.PERMIT FEE MECHANICAL FEE
OW I con ify that l have read this application and state that the above Information
a Jammed.I agmeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
T relating toesMeting construction,and hereby authodae representatives of this
F N city to enter upon the above-mentioned property for inspection pu rpuses. ALTERORADDTOMECH.
? (We)agree to save,Inde if an d kmp rml the City o1 Cupertino Date RCCCIPt#
V again fes,' d nts,cost and exp s ch mayinanywayamme AIR HANDLING UNIT GO IQOOOCFM) SUBTOTAL:
a nst>v a the m' arms Peet.^r. CONSTRUCTION TAX
AIR HANDENG UNIT(OVER 10,000 CFM)
Sgnaure of Appllten .nlrad.r Dms EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
Willtheapplicantorfuturc Befog occupant store or handle ha,cardous HFATING UNIT CFO 100,000 BM Date Recei t#
materialasciefindbythe vino Municipal Code,Chapter 9.1Z and the
I fralthand Safety Code Section 25532(a)2 1-MATING UNIT(OVER 100,000 BTU) TOTAL: ZC- 12
'❑Yes ' M No ��¢�
Will the applicant orfuturebuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) )SSIB]�AMATE
which emit haradous air contaminants as deleted by the Bay Area Au , n
Quality Maragement Diyesstrict? s BOILER-COMP OFT'OR 100,=BTU) I' I�
4 ivo nf.uo xl��/ H N V
(have read thehaza smateriab requirements under Chapter of BOILHR-COMP 100,000BNI
the Calflomla ITeath&Safety Code,Sections 25505,25S33 and 75536.I
understand that if the building does not correctly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.T-7 - pp6y,..L Pu�.{,�
responsibility to net ify the occupant of the requirements which most be met NQty VV�T.Y �f NN
prior to issuance of a Certificate of Occvpa ney.
Owner or authorized agent Dale TOTAL: ISSUEDBY; I "i kut(..
OFFICE COPY