20630 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr^'e I Identification 7 1'MCWT NO.
Building Address:
�oL�� � �• S P. `14S- 20630
e ma: one: q p p
A P V P%- € .J, ef e 5 S CITY OF CUPERTINO-BUILDING DIVISION
•
Cnntr ere: Name: Lk.No: APPLICATION /PERMIT�� BMLDINGELFGTRICALPLUMBINGMECIIANICAL CATEGORY CONTROL It
Architect/Engineer. Lk.No:
Q'ry ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: LICENSED CONTR SDECLARATION
POWTISSUANCE ❑ E:1
❑
Ih...by frmthatIsm licensed
under o nsofr9(commnc- APPLIANCES-RESIDENTIAL JOB DERBTION
IngwlthSMton7000)ofDlWgo3o(theBugnemandro(mionsCodeand
my
license is In full( effect. ELS
PAN
License lam Y.k I a� f ,
Date Contractor UP TO2DOAMM
A.MP5 `�
ARCHITECT, ECLARATI
07 f understand my plan shaBbeu mpub0c recoNa OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
,Q0 OSIGNSELECTRICAL
Licensed Profemiovl
<<nt OWNER-BUILDER DECLARATION
6' Ihercby affimndatlam exempt(romthe Cont raciorb LicenseLaw for the SPECIAL CIRCUIT/MLSC
F O p following remon.(Section 7Q)1.5,Businne and Pmfemlons Code:Any dtyor TEJg1P,METFR L NST.
countywhich mquimsa pemdt to wmtmR,alter,improve,demolish,orrcpair
anystrocture pdorto Its l ance,aborequires theapplicant forsuch perodro POWER DEVICES
p� file a signed statement that he is licensed pursuant to the provisions of the
03u' nn Contractor's License Law(Chapter9(commencingwith Section 7000)of Divi- NG 1,00 C VALUATION
O don 3 of the Business and Profemiov Cod e)or that he b exempt therefromand
59 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE SWI
19
<� appllcantfor a permit subjectsthe applicant to a civil penalty of not more than
p, 0 five hundred dollars(&500). NEW REST AL ELECTR
I,as owner of the property, FQFI. STORIES TYPECONSTRLCTION
p perry,or my employees with wages as theb sok
C 7.Q compensation,will do the work and.the stroctu re b act intended or offered for
y D sale(Sec.7061,Business and Pmfcmbv Code.The Contractors LlceneTaw
does not applyto an owner of property who Wlldsor improves thereon,and OCC.GROUT' RES.UNITS
whodoessuchworkhi s iforthrwghhisownemployers,providedthatmch
Improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement bsold withino^eyear^femopletl^n,the ownin,buBderwilltave
ir
th�urden^f prn.mg that he did not wild or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
LJ of property, FLOOD ZONE AI'N
I,act owner t p perry,am.7044,Business
ess and Pro with licensed PERMIT ISSUANCE D
The CoturatocovwcttheprojM(Sec.7006, tonere and of
Code: _(J
The Contractor's Llreve Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds t r Improvn thereon,and who contracts ice such p ojecb with a
<gW�actor(sexempt under ce tothe Contractor's License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ f am exempt under Bee. R&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. ,n SANITARY Y_ N_
• Owner Date V RECEIPT N
WORK MAN COMPENSATION DECLARATION O FIXTURES PER TRAP •.v SCHOOLTAX Y N
❑I hereby affirm that I have a wrtiftcate of consent to self-inure,or RECEIPT N
conificeteofWorkers'Compevetion Insurance ora certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS 0 PARK FEE Y N
3800,Lab C.) �' RECEfPTN
Policy Tray GAS FA.SYSTEM-OVER1(FA) -�
BUILDING DI VISION FEES
[PCenitted copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FT, Recvi t#
(Thissectlon need not M completed If the permft is forone hundred dollars
($100)orlem.) WATER HEATER W/VENT/E,vrLR OD ENERGYFEE Y_ N_
I cenRythat in the performance of the work for which this permit Is Issued,
I shall not c ploy a person In ray manner so m to a to the WATERSYSIEM/TREATING
Worker:( only 1 Ice. Dat — PAID
O Z ApplicantA NEWRFSIDENHALPLh1B. SQ.Ff. Date Recel t#
Z O NOTICET APPLICANT:If,after ng thWC teof Exemption,you
W ahwld subject to the Workan'Compeva n provision of the Labor TOTAL:
Code,you at fort hwith comply with such provblons or this permit shall be
BUILDING
FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercbyalfinnthat there is a construction lending agency for the perfonrys� ELECTRIC FEE
te
7 Z anof the work for which this permit b TOTAL:
02 MdeesNamc Issued(Sec.3097,Civ.C.) �•uV PLUMBING FEE C
LL F Lenders Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icenify thatl have reaithbapplicatl^nand statethat theabove Information
O W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to building contraction,and herebyanthodze representatives ofthis
F Z eltyto enterupon the above-mentioned property for inspection purposes. ALITRORADDTOMECH. Date RCCCIP[#
(We)agree to save,indemnify an d lump,harmlem the City of Cupertino
V against liabilities,judgments,coetsand expenseswhich mayin anywayacwe AIR HANDLING UNIT(TO 10,M CFM) SUBTOTAL: -Z'V
aga int said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 GEM) CONSTRUCTION TAX
Signature of Applicant/C^nt c1.r Dare E(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre wilding occupantat.m.r handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Ffealthand Safety Coic Section25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL: MW
❑ Ycs No
Will the applicant or fixture wilding occupant use equipment or devices VFNIILATION FAN(SINGLE RMID) TI f�DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP OHP OR IMM BTU)
[?yen
have read the harclo aomaterials requimnrnts under Chapter 6.95 of BOILER-COMP(OVER IDQ000 BN) JUN 2 8199)
the CaBfoMa health&Safety Cade,Sections 25505,25533 and 75536.I
` understand that tithe wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. FQ.FT. pp}y,
ruspovibllily to notify the occupant of the requirements which most be meCitt �CUIIQ�P
prior to Issuance of a Certificate of Occupancy. `-
Owner,or auth.dud agent Data TOTAL: ISSUED BY
OFFICE COPY