20477 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER.WT NO.
Build ing Address: - 20477
0 52 i iVi= 1
w crs ante: one: p q AFE
CITY OF CUPERTINO,BUILDING DIVISION O /2,�0
Contractora NsfaV - Lac,No: APPLICATION / PERMIT 4
e Gkf BLTLDINGELECTRICAL-PL47MBING-MECHANICAL CATFCARY COR LO
% AaMt ct/Enginnc Lic.No: _ C/S
Qry ELECTRICPERMIT FEE - BUI DING PERMIT INFO
Address: - ate..
-
LICENSED CONTRAROR'S DECLARATION I'FRNI TISSUANCE a,y
I M1erenthatl under
erpmsofar9c- APPUANCESREADEN77AL
InSedion 7ivisio3oftheBusinssandProfesonsCode,and my JOB DFSCRTTION
liceense1bin(uBto.
and
effe .
PANFIS
Claw LION
Date
Date Contractor ' UE IQ 200 NIPS
ARCHITECTS DECLARATION 201-1WOAMPS
RK Cz I understand my plans shall be used as public records. OVER 1 OOO AMPS - SQ.Fr.MOOR AREA $/ Q..Fr.
it d`j Licensed Professional - SIGNSELECTRICAL �1D�O(O /
G m OWNER-BUILDER DECLARATION
CI E3 SPECIALCIRCUIT/MISC
z59�0 owingrI hereby af@mthatiamexempt 31.5,B(mmthe saredPtractors ffestoLicense Law for the:Anyciyor `//
following reason.(Section permit
to Business and Professions Code:Any dry it
O f.� TFMP.METER OR POLE INSf.
� county rcqu4vaperMltomsxstruct,alter,unpmve,demolish,
anystmcture prlorto its issuance,also requleasthe applicant forsuch permit to POWER DEVICES
e.O file a signed statement that he Is licensed pursuant to the provlslom of the
Contractors License Law(Chapter9(commencing with Section 7000)of Diet- VALUATION
1n SWIMMING POOL ELECTRIC
,_�O 5 the hadflhe the alleged Profession Any)violaat tion
of exempttherc(rom and A, �� O
L5p' < the bass for the permit
subjects
exemption.
eap Any Notation of Section not re by any OU7LElSSWITCF3ESFIXTURES ,dl— Q O
��� applicant for a permit ubjMstheapp0canttoadvil penalty of not nnrethan /
five hundred delta.($500). NEWRESIDENTIALELECTR SQ.FI. STORIES TYPE CONSTRUCTION.. ❑I,as owner of the property,or my employees with wages as their sole
C7a compensation,will dothe work anithe structure isnot intended or offered for
O sale(Sec.7014,Business and Profexions Code:The Contractors Lirense law -
$ does not apply to an owner of property who builds or improves thereon,and
j^ who does such work himself or through his own employees,provided that such x OCC.GROUP RFS.UNITS
improvements arc not intended or offered for sale.If,however,the building or TOTA
improvement Issold within one yearofeompletlon,the owner-builder will have
the urden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FEcOD MNE MIN
u I,as owner of the property,am exclusively mntrac 8 with licensed PFgMIT ISSUANCE qqrs
contractors to construct the project(Sec.7044,Business and Professions Code: a�The Contractor's License law does not apply to an owner of property who ALTERDItA:N&VENT-WATER(EM Wilds or improves thereon,and who contracts for such ptojects -
with a FEE SUMMARY
c7aIl4actor(s)licensed pursuant to the Contractor's License Law.,LJ I am exempt under Sec B A P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Dace DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
RECEIPT#
'r WORIGIAN COMPENSATION DECLARATION FIXTURES- SCHOOLTAX Y_ N_
0-1
F11 hereby affirm that I have a certificate of consent to seB-Inurew a ITEC PT N
certiBat a of Workers'Compersiation Insurance or a certified ropy thereof(Ser. GAS EA. -t .40 RK FEE Y_ N_
3800,lab C.) RECEIPT N
Policy p
Com any GAS EA.SY 4 BUILDING DIVISION FEES
ffCertified copy is hereby furnished. GREASE/INDU LANCHECK FEE 'SY-a/Q
MCertified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP pAlj,,/.//
COMPRNSATIONINSURANCE S'EWERSANITARYSTORMEA.200FT. Date Recd t#$36./$
(Thissedion need not W mmpided If the permit Is forone hundred dollars
($10()nrlea,.)
WATER HEATER w/vENT/ELECTR ENERGY FEE Y N
I ormlythat In the performance of the work for which this permit is Issued,
I shall not employ any person in any manner u as to become subject to the
WATIIIt SYSTEM/TRGTING O
Workers'Compensation lawamr�lunmia. Date � PAID
O Z Applicant NEWRFSIDEISIIALPLMB. SQ.FT. Date Remi t# �Jipr'b
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
Fshould become subjM to the Workers'Compensation provisions of the Labor 6 TOTAL:
W
Cade,you=at forthwith comply with such provisions or this pemdtshall be BUILDING 1M 311, O
W j deemed revoked. ..
CONSTRUCTION LENDING AGENCY SEISMIC FEE 490,
a O I hereby affirm that there Is a construction lending agency for the perform~ ELECTRIC FEE
Z soca of he work for which this t Is issued(5ce.3097,Civ.C.) TOTA s
U O Landers Name permit PLUMBING FEE
F Lendcr'a Addmas QTY. MECHANICAL PERMIT FEE
Ow laftiythatlwvemadthieappuaunnand AatethaitheaWveinfo atmn .�s�'A MECHANICAL FEE
a iscorrM.Iagreetocomplywithallcityand muntyominancesandatatelaws PERMIT ISSUANCE 2sQ� FEES PAID:
relating to building construction,and hereby,authorlu representatives of this
H IO city to enter upon the above-mentioned property for Wpection purposes. ALTER OR ADDTO MECH.
Z . (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Reeeipt#
V atini labllltica,fodgments,costsand expenaeswhich may lnanywaytiame AIR HANDLING UNIT(TO 10,030 CFM), SUBTOTAL:
against said i in coma of the granting, t •permit.
taal(0 q AIR HANDLING UhTT(OVER IO,000CFN) CONSTRUCTION TAX 'Ze]
SignaturefApli onto<mr m V EKHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrdous HEATING UNIT(TO 100,ODO BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
HEATING UNIT(OVER 100,(X70 BTU)
hleallh and Safety Code pion 25532(a)t TOTAL:
rj YesNa
WBltheapplieant mea building occupant use equipment or devices VENIILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air FAM Q❑uality Marugement Dist et? BOILER-COMPOHPOR 1W,0(D BTU) i('(= M
Yesu o
have read the hair srmterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BLV) {�
understand that if the building does s netctcurrentllyhave5a tenant,rthat itlIs my NEWRESIDFNIIALMECH. SQ.FT. I:sr�
respors' ility,to notify the occupant of the requirements which must W met
priors uance ofa Cert'icate o[OccvFancy. ) s _ a.L�wepwaa
v'(fl�
Own aulhodud agent ate g' YE ISSUED BY:
70TAL 4G.
OFFICE COPY