20894 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addrxss:
20894
Phone: A A
_AV 17 /✓�g�� r`�� CITY OF CUPERTINO-BUILDING DIVISION
• c.i. °'''Kamp' Lie.No: APPLICATION /PERMIT
SS E L' I
5-1)313 BUILDING-ELECTRICALPLUMBINGMECFIANICAL CATECARY CONTROL x
Architect/Engineer. Ls.N.
^— ,� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
l.
Address I V S be I c 5 Yah PERMITISSUANCE '(m ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby offlan that l am licensed under provisions of Chapter 9(commenc APPUANCESRESIDENITAL JOB DESCRIPTION
Secum,7000)of Division3ofthe Buslness nd ProfnsionsCode,and my
license b in full and effect. PANELS
Llcen aa�Ltc.R 5 3 Z S L-Q k`t, S A�Q5
Date Gontverar 1
ARCHITECT'S DECLARATION 701-1000 AMPS
q�q�vv0Z0 Iundenatand myplamaluRbetad as pubberam,ds. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
k z Licensed Professional SIGNSELECTRICAL
�•< A OWNER-BUILDER DECLARATION SPECIAL CIItCU1T/MLSC
s. I herebyaffirm that lamexempt from the Contractors License Law for the -
Z 0... following reason.(Section 7031.5,Businessand Professions Code:Any city or n a
O Z' TEMP.METLR ORPOLRINST.
K anystm m rryuiroapemdttomno requiesthe applicant
t -
��.r any swcturcpdementa issuance,alsosed!pursuant to
he nwisihpeof permit POWER DEVICES
0 floe a signed statement that he(Chapter licensed a ncing it the pro Section 7000) of the
Co.3.ftr . melndProfiomC e)orthat withmmpthemtmfland SWIMMING POOL ELECTRIC j\��s
ial-
QF,�O�<" the basis fo the alsaandexemption. Any orlation tsxxempt 7031.5 many - VALUATION
y� .,-tt the bash for the alleged exemption. Any violation o(SectlOn 7031.5 Zany tC1
(gy p five hundred apears($5bjeas the applicant Toa civil pewlty of mat more than OUTLEISSWITCI-IISFIXNRES
yy
five hundred dollars he pr. NEW RESIDENTIAI.dECTR_ sSQ,FT,
❑I,as owner of the properly,or my employees with wages as their sole STORIES TYPE COn'STRI;C'fION
compenaation,willdothe work and thestruc[urelsnot intendedor offered for
$ O sale(Sec.7000,Business and Professions,Code:The Contractors License Law[i µ 4•i N j$� does not apply to an owner of property who WNds or improves thereon, \� F ,Fl V
wh.doessuchworkh1mSxV orthrough hisownemployees,provided that such ,,Oa�aar� OCC.GROUT' NES.UNRS
Improvements are not Intended oroffered forsale.Ifhoweverthebulidingor gra \
improvement Lssold within oneyearofmmplation,the owner-builderwlll have .LTOTAL: W
th-turdenof proving that he did out build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEEFI,OODZDNE nPN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
m
tractors to conetct the project(Sec 70K Business and Professions Code: `
The Contractors
License law does not apply to an owner of property who PETER-DRAIN& .WATER(EA)
Wilds or improves thereon,and who --toners for such ptojsces with a
CgWlado,(-)licensed punsumt to the CIou seols Licensee Law. BAIX FLOW PROTEST. CE FEE SUMMARY
L�I am exempt under Sec B&P C for this reason
Owner Date DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RECETT#
❑1 hereby affirm that L have a certificate of consent to axil-insure,or a FD(TURES PER TRAP SCHOOL TAX Y N
cerliBate of Workxrn'Compcmatlonlreurance ora certif4d ropythemof(Sec. RECEPT M
3800,Lab C.) GAS FA.SYSTEM-1 INCAOULLELS PARK FEE Y
Policy Mam RECEIPTNN
X
Cany GAFA -OVER4(EA) BUILDING DIVISION FEES .
�CfrttBed copy ls hereby furnished. S
❑Cedifiedcopy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXMPI'ION MOM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(TMsseaton need not be completed if the permit Is forom hundred dollars SEWER-SANITARY-STORM EA.700FT, Date Rcmi t#
($100)or Icss.)
Icertify that Nthe performance oftheweek forwhi<h this permit IS Was,,j, WATER HEATER W/VENT'/ELECTR ENERGY FEE Y_ N_
I shall not employ any person in y manner so co wb ct to the
Workere Com sail laws o(-Cjlifomla.Date b _e"3— WATER SYSTEM/TREATING PAID
-
zZ Applicant
Z0 NOTICE TO AI'PLICAM:U,aftermSIMmngthk Cedaioteofaemption,you NEW RESIDENTIAL PLMB.__SQ, . Date Recei t#
should brooms sultyd to the Workers'Comperesetlon provislons of the LaWr TOTAL:
U7 Code,you must forthwith comply with such provislom or this pemdt shall
W ? d""pd revoked' BUILDING FEE 1 r0
CL p consrgucrloN LENDING wcpncv SEISMIC FEE t
I hereby affirm that there Is a--atrualon lending agency for the perform
Z sour of the work for which this permit is haued(Sec.3097,Civ,C.) TOTAL: ELEC'T'RIC FEE
V 0 Lender's Name w t�0
LL H Lender's Addm�pQTY. MECHANICAL PERMIT FEE PLUMBING FEE
O LUIcertifythat l have read this application and stamthat the above Information MECHANICAL FEE
M b-'mer.I agree to complywith all cityand county ordinances and slate laws 193?MLT ISSUANCE FEES PAID:
Nrelating to building comtmerl-,end hereby authorize representativeso(this
1"' Z city to enter upon the abovnmembKd property for Inspection purposes. ALTER OR ADD TO MF-CH.
(We)agree to save,Indemnify an If keep harmless the City of Cu perlio nDate Receipt#
against Babiilttes,Ndgmsnts,costa and expenses which may In any way accrue AIR HANDLING UNIT 10,000 CFM)
agai tsal City In<mnae uence O(the gvnttng of this penult. SUBTOTAL:
9VW(W/DUCT)
ANG UNIT(OVER CFM) CONSTRUCTION TAX
5lgoature of Applin t/Contractor s IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardousNIT(TO 100,ODO BTU)material as defined by the CuyaIII Municipal Code,Chapter 9.17,and theDate Recel t#
Flea lth and Safety Code,mon 7b537W)7NIT(OVER 100,000 BTU)❑Yes No OsTTALi
Will the applicant orfuturebtilding occupant use equipment ordevicesON PAN(SINGLE REBID) tSSUANCE"U LL,which emit hazardous air contaMvntsa defined by the Bay Area AvQuality Management Dist MP pFE'DR 1W,IXq BTU)4 Yea 6 -�9su
have read the haza nus materials requirements under Chapter 6.95 ofP(OVER 100,000BN)
the Califomb Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building doea not currently have a tenant,that it ls my NEW RESIDENTIAL MECH �
. SQ}7, C�
resposubillty to notify the occupant of the requirements veld must be met rBfJP
!i r{-n(]
Pdo uses,of a Cert cats of Ompancy.
mer or out orlu agent Date >�C�al�., tM"-ye.^ x.
TOTAL: ISSUED BY:
OFFICE COPY