20247 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification I
Building Address:
«6.5z $?_LoGr_ _FAP-� <---C
PUI TNO.
20247
sera Iii. Phone:
It, LL
CITY OF CUPERTIN6BUILDING DIVISION.
APPLICATION / PERMIT
IL
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caRtradar'e N,me: Lia. Na:
BITILDINGELECTRICALPLUMBING-MECHAMCAL
CATEGORY
CONIROLN
A Ited/En®ear. Lie. N.
QTY'" ?..ELECTRIC PERMIT j' .;-:FEE
' BUILDING PERMIT/NFO,
Address: '7
PEU.UTISSUANCE -
E] O El
CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
Therebyaffirm that Icess licmaed under provisions of Chapter9(comment,
Ingwith5edion70M)ofDlvbion3ofthe BualnesaandProfeuions Code, and my
licences is ifull soros and died.
c
License Clae m Llff if
JOBDESCRUMON
PANES
Date Contractor
�-s ARCHITECTS DECLARATION
I undentann pry Flamahall by Necd/p pu Bc records
�Ji f6F
201-1000 AMPS
OVERIWOAMPS
SQ. FT. FLOOR AREA
S/SQ. Ff.
SIGNS ELECTRICAL
/a'
Licensed Proftonal
OWNER -BUILDER DECLARATION
I henebyaffurrmthat I am exempt fromthe Contractors Limnee Law forthe
following reason.(ScMon7(31-5, Business and Professions Code: My city or
muntywhieh nequcresa permit tomrutruct, alter, Improve, demolleh,orrepalr
anystrodure prior to its Issuance, -line requires thesppBant for such permit to
foe a signed statement that he is licensed pursuant to the provisions of the
Contrsdoes License Law (Chapter 9(commanding with Section 7000) of Divl-
don 3 ofthe Business and Profeed ru Code) or that he iseaempt therefromand
the Iasis for the alleged exemption. My violation of Section 7031.5^
by any
applicant fora pemdt subjects the applicant too civil penalty of not mare than
five hundred dollars (SSOB).
❑ I, as owner of the property, or my employees with wages as their sok
mmpeasation,will clothe work, andthegrocture, is not Intended or offered for
sale (Sec 70K Sualness and Professions, Code: The Contexctue. License Law
does Rot apply to M owner of property who builds or improve therron,and
who doessuchwarkhlmvelforthmugh Msownempluyere provided thatach
Improvements arc not Intended oroffered (waste. If, however, thebullding or
improvementlssoldwithin oneyearofcompletim, theowner-builderwBl have
th�r,�urden of proving that he ddidno[bu0d or lmpmve (or purpose o(ule.).
u L as Owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec44, 70Business and profession, Code:
The Contractor's License Law don not apply to an owner of property who
builds Or Improves thereon, and who contracts ct
for such p4ajes with a
cgR(faCar(al Bcenxd pursuant to the Contraa ar's License Law.
LII am exempt under Sen B k P C for this reason
SPECIAL CIRCUIT/M15C
7pMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSW[TCHFSFIXTURFS
VALUATION
aD OOQ-C$
..+
NEW RESIDENTIAL ELECTR _SQFT.
STORIES
TYPE CONSTRUCTION
TOTAL:
jS 1,T '
QTY -,- -PI:UMBING PERMFFx t i' ;SrFE$G
PERMIT ISSUANCE
ALTER -DRAIN& VENT- WA,�i(EAI
OCC. CROUP
RFS. UNITS
).TpOD 7pNE
APN
BACK FLOW PROTECT. DEVICE
a
3' "`-'y'-:.;FEE SUMMARY. `- `-- ,.'
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certlfiate of consent to sel4Inare, w
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT s
FIXTURES. PER TRAP
SCHOOL TAX Y N
a
certUlate.(Workers' Compensation L...carscertified copy tre
heof(Sec.
3800,IAb C.)
Policy Y
RECERrTa
GAS EA. SYSTEM -1 INC.4 OUTLETS
PARKFEE Y N
RECEIPT a
Co any
EC21fiified copy ishereby th the cid.
❑CertJed copy is filed with the city inspection division.
GAS FA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISIONFEE$
PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMsseneed not be completed lithe permit is(carcase hundred dollars
(St0()orless')s.)
Mat In the a l.e 1.c issued,
Ill
PAID
Date Regi t#
2�
`�
GRFASETRAP
SEWER -SANITARY -STORM EA 2DBIFT
WATER HEATER W/VENT/ELECTA
ENERGY FEE Y N
Am Person, i
I shall RO employ any peam In any rtunner a u to become abject /o the
any manner an 0 to suby
Applicant Lawn of California. Date
NOTICE
NOTICE 70 APPLICANT-. R, wryer making this CertBkale of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Cade, you mat forthwith mmply with such pmvisiam orthis permit shall be
deemed revoked.
PAID
Date Recei t#
WATER SYSTEM/TRFA'RNG
NEW RESIDENTIAL PLMB.__SQ.FT.
TOTAL:
IN
TOTAL:
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a coaatmdlon lending agency for the performELECTRIC
Ana of the work for which this permit is Issued (Sec. 3097, Civ. C.)
SEISMIC FEE
FEE
finder's Name
Landers Address
IRMITx.,;,,
certifythat I have readthisappBoh-n.M gatetbatthe above Inf..tion
is mired.] agree to comply with all city and county ordinances and gate laws
relating to building mretadion, and hereby,uthome, representatives of this
city to enter upon the abovsmentioned property for inspection purposes.
(We) agree to ave, Indemnify an d keep harmles the City of Cupertino
againgliabWties,judgments,mgsand expensewhich rayl. anywayaccrue
ZSUBTOTAL•
against said City in consequence of the granting of this permit.
QTY.„, MECHANICAL.PE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT If010,” CFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Sigamre Of AppRcam/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harzrdous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
He❑altYnd Safety Cade, SeNloon 75532(x)7
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,00 BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will the applicant or future building occupant use equipment or devices
which eM1 harardom air conlaMnams as dellned by the Bay Area Air
Quality Management D❑iissttjrict?
4haweread the hazardausmateriaisrequlmmentsunderGhapte, 6.95 of
the Califwnla Health A Safety Code, Sections 25505, 25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
rnpora I tonctlfy the occupant of the requirements which at be met
VENTILATION FAN (SINGLE REBID)
&4WRNCE DATE
--
i
^;iy p{ PIf�eT''jplT.
- --
BOILER -COMP OHPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MEC -I. SQ.F7.
prior o fastainice of a Certl(Icate (Diss,
ISSUEDBY��O
—
.1 a : Breda est V Date
TOTAL:
OFFICE COPY