20919APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
Building Acidness:
PERwrNo.
'
91 9
ICA -33-3 VALc-C� -F'A� i�wA7'
20919
era one:
T4 AD>Sl -9 e hPuraP_'.s N Z$
-A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
1; -2 7
V _ _L
cat t>`ractor•.IVtime: 1 _ 15 c. Na:
BUILDING -ELECTRICAL PLUMBING -MECHANICAL
CATEGORY
'CONTROL#
Architect/Engloeer. . - LIZ No:
QTY ELECTRIC PERMIT FEaaE�s
BUILDING PERMIT INFO '
Address: 6Ss�, 4-0-,
❑ 1:1❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
-
I hereby affirm that l am Licensed under provinfona of Chapter9 (commence
APPLIANCES -RESIDENTIAL -
]OB DFSCRIPIION
i PANELS.
1UP TO 200 ANTS
fngwith Section 7000).(Divisiod3ofthe Busimmand PmfendomCode, and my
licinse Is in lull force and effect.
LDcen clam G ate C nt#resor J Fy
201-1000 AMT'S
ARCHITECT'S DECLARATION—
I understand my plares.hzll be used as public records
OVER1000AMPS
SQ.FC.FLOORAREA
$/SQ. IT.
SIGNSELECTRICAL
Licensed Professional
SPECIALCIRCUTT/MISC
OWNER -BUILDER DECLARATION
I hereby af0rmthat I am exempt fromthe ContnRor's License Law for the
-
TEN(P, METEROR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a permit to mrutruct, alter, improve, dernoll.h, or repaf r
anystructure prlorto its iseoance,alsorequire.theapplicant forsuch permftto
file a signed statement that he in licensed pursuant to the provuloas of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9(rommencing with Section 7000)of Dlvl-
slon3 of the Business and Professions Code)mIled he 1n exempt therefromand
VALUATION '
The balls for the alleged exemption. Any elolatian of Section 7011.5 by any
applicant for a permit subjecbthei ppllcantto a civil penalty of not morothan
OUTLETSSWITCHFSFI)TURES
fivehuncireddollan($500).
I, as owner of the property, or my employees with wages as their sole
compensation, wBldothe work and the stmcture bnm Intended or offered for
NEW RESIDENTIAL ELFAT2 SQ.Ff.
SL
2//
7YI'E CONSTRUCTION
' 1
k S 14P
sale (Sec. 70K Business and Professions Code: Code: The Contractor's License Law
L
does not apply to an owner of properly who Wilds or improves thereon, and
who does sechw.r4 himself or through his own employees, provided that such
improvements are not Intended or offered for sale. If, hmvever, the building or
Improvement U sold within oneyearof compleded, the owner-bullderwill have
tlAIlurden of Foreleg that he did not Wild or Improve for purpose of sale.):
u I, as owner of the property, am exclusively contracting with licensed
contractor to construct the project (Sec. 7044, Business and Professions Code:
TOTAL: t b
QTY, PLUMBING PERMIT FEE
OCC. GRO
HIS. UNITS
FLOOD ZONE
APN
-
PERMIT ISSUANCE
'
The Contractor's License Law dean not apply to an owner of property who
Wilds or Improves thereon, and who contracts for each pSojects with a
cgIlt cum.) Licensed pursuant to the Contractor'. License Law.
I� I am exempt under Sec. B k P C for this reason
ALTER -DRAIN & VENT - WATER (EA)
FEE SUMMARY
RACK FLAW PROTECT. DEVICEOUTSIDFITES
DRAINS FLOOLZ ROOF, AREA, COND.
SANITARY , Y_ N_
RECEIPT #
OwnerDate
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a cete rtificaof consent to seBd esum, or
certificate of Workers'Compereatfon lnsurnnce ma certified copythereof(Sec.
lab CJ
pLYTIJFffS PFR'1 72A1r
SCHOOLTAX Y_ N_
RECENT #
GAS -1 INCA OUTLETS
PARK FEE Y N
RECEIPT #
Policy
llry p an
Co y � �
GAS EA. SYSTEM -OVER d (EA)
-t BUILDING DIVISION FEES '
ffc-odRed copy is hereby furnished. -
Coolfrd copy V filed with the city inspection division..
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
'
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thissertionneed not becompleted lfthepermit lsforone hundred dollars
SEWER-SANITARY-SIl7RM EA 200hT
Date Recei t#
� WATER HEATER W/VENC/ELECTR
.
ENERGY FEE YN_
-
($100)or Tesla -
Icertifythat In the per(omunce of thework for which thio permit ie insect,
WATERSYSTEM/TREATING
I shall net employ any person In any runner n as to become subject to the
Workera'Compeneatbn Lawn o(CaB(ornla. Data
PAID
,
NEW RESIDENTIAL PLMB. SQFC.
Applicant
Date Rewi till
NOUCETO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compersatlon provisions fthe Labor
- TOTAL:
BUILDING
Code, you must forthwith comply with such provisions orthh permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
,
I hereby afRreathdt there he acorstruction lending agency for the perform
ance of the work for which this permit is Issued (See, 3097, Ov.C.)
lander. Nana
Lender's Addrese
I certify that have mad this application and state that the above Information
Iscorrect. l agree to complywith all cityand comayordinances and state laws
.• TOTAL:
.ELECTRIC FEE
b
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relatingtor pont corotro-rrentionhereby authorizerepresentatives of this
dty to Wenterupt the abed ify a d property for lrspealt purposes.
(We) agrre to ,indemnify en d keep her ;the City o(Cu ertlno
e
agafnatl, III , dgmenb, conte end expen h rosy In any ova a
ALTEROR ADD TO METH.
Date Receipt
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
against sal It nconseyuence oftM gra g hie pernit
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
S na pllcant/Contractor ate
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
'x HAZARDOUSM ERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
• exacrlal'as defined by the Cupertino Municipal Cade, Chapter 9.12, and the
Health and Safety Cod u tion 25532(s)7
Yes o
Will the applicant Lure Wilding oavpant use equipment or devices
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTO) -
-TOTAL:,
VErIILATION FAN (SINGLE RFSID)
- IS DATE '
which emit ---..a air contaminants as defined by the Bay Area Air
BOILER -COMP OLD OR 100,000 BTQ
Quality Management Dist ct7
❑Yo o
)have read the haze ous matcriab requlrcments under Chapter 6.95 of
-
GdJ I*
�� at
BOILER-COMP(OVER 100,000 BTU)
the California Health& fety Code, Sections 75505,25533 and 75534. I
understand that if the building does not comently have a tenant that It Is my
NEW RESIDENTIAL MECH. S0FT.
responsibility requlrer nt^ mu�belrM�
Cftioccu.fDr(lhe
prior to Lssua aC�ertiB.c�ajte�o(Ompancy:
ISSUEDBY:
neror orf grist - Dade%
TOTAL:
OFFICE COPY