20652APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
(A B.ildi.x Project Identification
Building
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PERMIT NO.
20652
wnera ams: one:
p (.neS 25275
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I CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDINGTLECTRICALML BING-MECHAMCAL
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c°"mannr'cN : n .-a"mLLNo
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LS '� SIGis a. r / 3 { !9
CATEGORY CONTROL N
Architect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addroge ���
PERMITIS5UANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm But l am licensed under provisions of Chapter9(commme.
tngwlicanscisin ullf000)o(Dlvislon3 ofthe Buailn1eseand Professions Code, and my
LlrenseiClass ll fo Lic. .. �3
Continuator—
Data ARCHITECTS DECLARATION
lunderstandmyplarusBbeusedaspublicrecords.
`
APPLIANCESRFSIDENTIAL
JOB DESCRB'fION
1 h Al� � J Ll 64%4 I IL�
�ra//`�-��,�a 7. F 1,
I r 1 Ni.OfFla Wrl .
-
PANELS
12 IQ 2M AMPS
201-1000 AMPS
OVER 10DO AMPS
SQ. Fr. FLOOR AREA
SM. FT.
SIGNS ELECTRICAL
Licensed Professioml
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the
following reason. (Section 70315, Business and Professions Code: Any city or
countywhichrequireapem tW.ro tru 4alter,improve,de=lMh,ormpair
file a signed statement that M is licensed pursuant to the provisions of the
Contractor's License law (Chapter9(commenciag with Section 7000) of Divi -SWIMMING
sion3 of the Business and ProfessionsCode)orthat he a exempt therefrom andV^ALUATION
the basis for the alleged exemption. Any violation of Section 7MIS by any
apphmnt fora permit subjects the applicant to a civil penalty of not more thanu-
anyslmcture prientoltsbauance, also requlresthe applicantfor, such pemdttoJMTITAL
five Lass owner of heir.
ML a owner of the property, or rry employee with wages as their sole
SPECIAL CIRC MLSC
TEMP. METERO LEI Sf.
POWER IN
✓l,.l
STORIES
TYPECONSTRUCTION
cole(Sac lion, iii for
k,andt..
sale (Sec 7044, Business and Codeure
Business and Professions Code: The
: Th. ,tract eoicarea
License Law
to or improves
don not apply to an owner of properly who n buildsorimproves thereon, and.00C.
who dceasuch workhimselftintended
ntde through his ownlimp,ogees, provided that such
Improvements am issold ithindrwyearfered for mpleftle. the owevegthe bulMl have
improvement eeoMwithin oneyear°(complMbn, eMowner-bu0derwill have
t1p*rden of proving that he aid not bulla or improve for purpose of wle).
u L as owner of the property, am exclusively contracting with licensed
contractors to conetrnct the project (Sec. 7044, Business and Professions Code:'
The ContaRor's License Law don not apply to an owner of property who
Wilda or improve thereon, and who contracts for such p(ojeca with a
cyR[�ec wor(s) licensed pursuant b the Contractors License Law,
LJI am exempt under SB & P C for the reason
QTy, PLUMBING P IT FEE
PERMITISSUANCE
ALTER -DRAIN & VENT - WAT1R
GROUP
RFS UNITS
FLOOD 7ANE
APN '
HACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTS I UP FEES
7
DRAINS FLOOR ROOF, AREA, COND.
FD(NRF_S PER TRAP
SANITARY Y— N—
RECEIPT If
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to
SCI{DOL TAX Y— N—
self -insure, or
certificate of Wru
urkeWCompeation Laurance nracertified mpythereof Twe
RECFR4 N
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPTN
PdiryN
Com ny Iyl
GAS EA. SYSTEM -OVER 4(FM
BUILDING DIVISION FEES
[PCetified copyh hereby furnehed.
�Cetmm ropy a nlea with the dry irepemun aiviainn.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
,
'
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(The section need not be completed If the permit e(orone hundred dollars
($11 Wililess0.
thew an as t whichthispert Mait to thencl,
Icenot emplhat oy an person nce
not employ any person in any ner eo a to become subject to the
I Workers
W plica'Compeneation Laws of carnia. Date
Applicant
PAID
Dale Remi t#
SEWER-SANITARYSTORM F.A.2D 1,
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
'
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB:SQ.FT.
NOTICE IU APPLICA : Lafter makingper ationiprovisions
ro is Exemption, you
Code,shoulbecomesubject to the plywit' such provisionsorthimu°fthe Labor
deemodourceatforthwith comply with-suchprovelorm orthe permit ahallM
deemed revoked.
TOTAL:
BUILDING FEE
.y U
TOTAL:
SEISMIC FEE
V
CONSTRUCTION LENDING AGENCY
I hereby affirm that there eacenumction lendingagency forlhe perform
ance of the work for which this permit a Issued (Sec. 3097, Civ, GJ
ELECTRIC FEE
Lender'. Kane
minders Address
Ioxtilythatl Mvereadthe application and stalethallheabove information
e rorrect.]agree to comply with all city and county ordinances and nate laws
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
'
PERMIT ISSUANCE
FEES PAID:
relating to building commaction, and hereby authorize representatives of this
citytoenter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmlem the City of Cu Fenton
-
ALTER OR ADD TO MFCH.
Dais Recei t#
against liabilities, judgments,"sand expenses which may in anyway accrue
againat said City in consequence of the granting of this permit w
_D so—'!e,
AIR HANDLING UNIT 10,ODOCFM)
SUBTOTAL•
AIRHANDIING UNIT (OVER 10,=CFM)
CONSTRUCTION TAX
Signalureof Applicant/Contractor Date -
EVHAUS'r HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
HEATING UNIT (TO 100,000 BTU)
Wllltheapplicanlorfulure building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Date ReCel t#
HEATING UNIT (OVER 100,000 BTU)
- -
TOTAL:
4
I lealth and Safety "g on 25532(a)f
n'Ye No -
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
nt usedby theequipuentArnAevices
IBthe applldousa tontamiaingnts occupaas defined
which emit hazardous air contaminants as defined by the Bay Arca Air
BOILER -COMP OHP OR 100,000 BTU)
Quality M. Bement
[?Yea No
"
have read the h Esrnaterlala requirements under Cha pier 6.95 of
BOILER-COMP(OVER 100,000 BTU)
the California Health & Safety Code, Sections 25505,25S33 and 25534. I
_
NEW RESIDENTIAL METH. - SQ.FT.
understand that if the building dcea not mrrently have a tenant, that it is my
responsibility to nobly the occupant of the requirements which must be met
prior to nuance of a Certificate of Occupancy. /'y
_D —
1(l
ISSUED BY:
Owner or auth Fact Data
TOTAL:
OFFICE COPY