20974 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addmn: . 20974
/o T3 Ne U
cases ane: _ one: q
M A " �0 8-0`41- % T O N70• CITYOFCUPERTINO-BUILDINGDIVISION
ConHaciors Name: Lm.No: APPLICATION / PERMIT l ll V
Architect/Engineer. Lt.No: BUILDINGELECTRICAI T'LUMBINGMECI-IAMCAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE VI) TAX ❑ ❑
LICENSED CONTRACTOR'S DECLARATION IL`
I hereby
r am thoemed
ounder provisions of Chapter APPLIANCESRESIDENTIAL
InSectio7000)oDtAshm3oftheBusincosand PmfeselonsCod,,and my ODESl'CRI I'�TION5
Ilceersel.Infullirmand PANELS
lim'
Licenso Clan Ic,#
Date Conenctar —UP TO 2DO AMPS
ARCHITECTS DECLARATION 2014000 AMPS
9
0�y O I understand my plane shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 6/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
I<-:! OWNER-BUILDER DECLARATION VECIALCI(CUIT/MISC { CX
t, Ihereby of oothe lam exempt from the Contractor's License Law for the
following reason.(Section 70115,Budness and Profesalons Code:An ci or
O sTEMP.MEfIR OR POLE INST.
g countywhie,Ivimtesapermktoroorequiresth,Impmvgdemolbh,ormit to
Q'� anysimctureoxtementehwancgaleoard pursuant t the ro such permit of to POWER DEVICES
�� file a signed tlatement that he V I.need pursuant to iM pmvblons of the
305 u, Comrsome.License Isw(CMpter 9(commencing with Section 7000)of Divi- VALUATION
sbn3ofthellusiness and Profession Ccede)mthat he is exempt therefromand SWIMMING R70L ELECTRIC
& the basis for the alleged exemption. Any violation of Section 7031.5 by any .I p O
appli.ntforaper teubjedatheappllcanttoadvllpemityofnat .than L OUTLETSSWITCHESHXTUR
ve ndrM dollars(f.AO. NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
I,as owner,of the property,or my employees with wages as their sole
t m nmtlon,willdatheworkandthestmmn6notlntendMaraffecadfor
O sale(Sec 70Ly Buslnesa and Professlom Cade:The Contractors License Law
S$
does.otepplytoanowner ofp.pertywho Wilda orlmprovesthemon,and OCC,GROUP RFS UNITS
whodoeseuchworkhimselforthrough Neownemployees,providedthat such
Improvements are not intended reoffered for sale.If,howevegthebuilding or TOTAL:
improvement issold within omyearafcompletlon,the owner-builderwiil"ve
tlg:kurden of proving that he did ns.Wild or Improve for purpose ofnloJ. QTY, PLUMBINGPERMT FEE FLOOD ZONE APN
L_f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094 Business and Professlom Code: ,
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
builds or improvsa theorem,and and who contracts for such p{ojects with• FEE SUMMARY
c9au.dor(s)Bmnrtd pursuant to the ContnRors License Law. BACK PLOW PROTECT.DEVICE
Lec I I em exempt under SB &P C for this reason
Owner Date OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CDND. SANITARY Y_ N—
WORKMANCOMPENSATIONDECLARATION NNY
[:]I hereby affirm ETXTUREs PER TRAP SCHOOL TAX Y_that I have a.rti0cate of consent to self4mone,or a
.Hificam of Worken'Comapami.m Imuran.or.certified copy thereof(sec. RFGEIT Y
3600,Lab C) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Policy Y GAS EA.SYSTEM-0VER 4(EA) RECEPT M
Co any BUILDING DIVISION FEES
FCertified copy ts hereby with the
GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑ etllled copy is here with the city Inspection division.
CERTIFICATE OF F3(EMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date Remi t#
(Thlesactlon need not W completed the mi
pert 6 fm one hundred dollars
(s1E0)orless.) WATQi HEATER W/VENT/h].1GTR - ENERGYFEE Y N
I certifythat In the perfm
orrnce of the work frrwhlch this permit is is.ed,
I she8 not employ any person In any manner sr an to become subject to the WATFR SYSTEM/TREATING
Workers'Compensation lawsof California.Date PAID
ZZ ApplNOTICE NEW RESIDENTIAL PLMB. SQFT. Date Repel t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should be..subject to the Workers'Compensation provisions of the Labor TOTAL:
CC (A Code,you resat forthwith comply with such provisions orthis permit shall be D ILDIN
W > deemed revoked. '
EE
a C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirmthat there is a construction lending agency for the perform - TOTAI: ELECTRIC FEE
Z arm of the work for which this permit is Issued(Sec.3097,Civ.C.)
V O Lender's Name - PLUWING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W T.dlfythatl Mvemadthlsapphcatlonand etatethai iheabuve in(omution
bmroect.lagr.tocomplywlthaBcityandcountyordinan.sandratelawe PERMTTIS5UANCE FEES PAID:
>. IL relating to building construction,and hereby authorize repereentatives of this
N
F city to enter upon the abovcmentloned property for inspection put rpom. ALTERORADDIOMECH.
? (We)agree to save,Indemnify an d k.p harndess the City of Cu pertlno Date Reeei t#
V age lost liabilities,Ndgments,costs a cad expenses which may In any wayaccme ATR HANDLING UNIT(TO 10,M CFM) SUBTOTAL'
against said City In consequen oftmgm 'n ofthlepermit.
-D AIR HANDLING UNIT(OVER Ie(00CFM) CONSTRUCTION TAX
Signature ff Applicant/Co r r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAMRDOL75 MATERIALS DISCLOSURE
Will the applicant or future building ons pant store or hand le hazardous HEATING UNIT(TO 10%000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
HealthandSafetyCode .25532(.)7 HEATING UNIT(OVER 100,000 BTI) TOTAL:
Yes o
Will theapplia or building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hawrd'us air. lamimnts as defined by the Bay Area Air �®
Management DAriSP DANBOILER-COMP DHP OR 100,000 BTU) p
es 6 O
v
e read the h a aomaterials requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTI)
the Ca Mornf.Health&SafetyCad,Secti..25505,ZSS33,.d2S534. I �p 5199
understand that lithe building does not currently have a tenant,that it it my NEW RESIDENTIAL MECH. SQFT. [[
responsibility to notify the occupant of the ire is which mu at be met e.{;sa11'ee�A h
priortoiss cefaPerlificate n 6{ffi�aNJ
Owner or adthodzed agent Date ISSUED .
TOTAL:
OFFICE COPY