20969 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification :PERMIT NO.
-Building Addreac: 20969 0n^n
caner. sate: hone:, A A
a -,9;,20 CITY OF CUPERTINO-BUILDING DIVISION
c.nrado?.Na LIc.No: APPLICATION / PERMIT S'4
U l
rchlted Fa neer. BUR.DING-ELECT121CALMP BING-MECIiAMCAL CATEGORY CONTROL It
Lic.No
/h0/]041 QTY
mc ' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddJuAg �. e4 PERIATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIO Vi-d"
' Ihereby
affirm that lam licensed provisions ofC9( enc- APPLIANCES-RESIDENTIAL
Invdion )ofDivslon3oftheBusimsandAvfesionscoeandmy JOB
D►D
/71jp4
licee.sci.In(tIlitoce defect.
PANELS
'License Class - .X ,
Date Contactor de ARCHITECT'S DECLARATION 101"1000 AMPS
pp�r9X I understand my plana shall be used as Public records: OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
al Z Ej Licensed Professional SIGNS ELECTRICAL -
E•6 OWNER-BUILDER DECLARATION SPFF.IAL CB2CUIT/MIST
z I herebyaffirmthatlamexempt frornthe Contractors Liconse Lawforthe
QQ ((�� following reason.(Seaton 7031.5,Business and Professions Code:And or
F"f'sy c.untywhichrequlre.apemdtw.rutins,alter,lmpmve,de=lbh,orrepair TFAIP.METERORPOLEINST. r \\
any smtcrore prior to its bwaMe,also requires the applicant for such permit to
�0. file a signedstatement that he Is licensed pursuant to the provisions of the POWER DEVICES ]
Gw� Contract.?.License Law(Chapter 9(commencing with Seaton 7000)o(Dv" /
� s alo.3of the Business and Profeseloru Code)orthat he b exempt therefrom and SWAiMING POOL ELECTRIC L TION
0 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTT.ETSSWITCI-]ESE%TURES
applicant for a permit subje Lcivil athe applicantto a penalty of not more than
five hundred dollars($500).
NEW RESIDENTIAL ELECTR SQ.FT. STDEES TYPECONSTRUCTION
�n ❑e as owner of the property,or he employees with wages as there sale /
c 1.IS.. 0Kion,willclothe goal .....d Professions
Code:
rehe Contacted License
d for
Law
doe(Sec.apply
In anowandf pmpe y Code:The or improve,
License Law )
r3� whorles tapply took himsa orthrou h who buinempoyeproovidedreoryand hat such OCC.GROUP RES KNITS
whodaem nts am kNmsendedoroffered ownemployens,pr,theb building
or
Improvements sold within
oroffered for sale.the oweveg ilderwdingve TOTAL:
improvement ieeoldwilhinoneyearotcompldloMiheowner-bulklerwill have
tliturden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constroct the pmject(See.7044,Business and ProfessionsCode:
The C.atrsdo?s License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such p(ojects with a ALTER-DRAIN&VENT-WATER BRA)
c (.)licensed pursuant to the Contractor.License Law. FEE SUMMARY
exempt under Sec. B&P C for this mason BACKFLOW PROTECT.DEVICE OUTSIDE FEES
77
DRAINS FLOOR.ROOF,AREA,CONI. SANITARY Y_ N—
RECEIPT Date RECIDrT X
WORKMAN COMPENSATION DECLARATION
Fl%NRES PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have o Issurate of consent to copy
oracertificRFC=
MOD,Lab
of Worken'Compensafonlnsursnce ora certified copy lherrof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Polity X - 0 RECEIPT X
Co.CGAS F.A..SYSTEM-OVER 4(EA)
BUILDING
DIVISION FEES
edified copy e y furnishe
JY Certified copy b(fled with the city inspection division. GREASE/INDUSTRL WAKE INTERCEPTOR PLANCHECK FEE
,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SFWERSANTPARY-STORM EA 200FT Date Recei t#
(TM1lseedian need nM be completed If the permit lafor one hundred dollars
(SI I cerifess.) 3yAy.pR�A.I.�3N/YEN'[/¢�.I.R ENERGYFEE Y N
I certlfythaHn the performance of the work for which this permit la issued,
I shall not employ any person in any manner so cue to become subject to the 4ypT(.g SySTEM/TRFAITNG
W.ekcr%Compensti.0 Lawsof California.Data PAID
0 Z .Applicant NEW RESIDENTIAL PLMB. SOFT. Dale Recei t#
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CC N Code,you meat forthwith comply with such provisions or this permit shall be BUILDING W `> deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Thereby afflrmthat there Lsaconstmctlon lending agency for the perform ELECTRIC FEE
M Z once ofthe work for which this pormit la issued 15ac.3097,Civ.C.) - TOTAL:
02 Lenders Name PLUMBING FEE
ly F Lender'.Address QTY. MECHANICAL PERMIT FEB MECHANICAL FEE Da
OW Icedifythatl haveread this eppBatlonand s[atethaltheaboveinformati.n
a lacomed.I agree to comply with all atyand county ordinances and gate laws PERMIT ISSUANCE. FEES PAID:
N relating to building construction,and Mreby authorlu representatives of this
H city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReCelpt#
.gamat Iiiifliticajacigmeme,cod.and expenses which may In anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) y1 SUBTOTAL:
S
consequ.' . Ci 7.of the granting of tale rmit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Ig a of Applicant/Contractor r Date allAUST HOOD(W/DUCT) CONSTRUI 'TION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Code Seaton 25532(a)7 HEATING UNIT(OVFR 100,000 BTU) TOTAL: .
❑Yea o
Will the applicant or ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANC-E DATE
which emit havardous air contaminants as defined by the Bay Area Are
silty Management District? r BOMERCOMP OEm OR 100,000 BTU) •4?
L�+�Ys � gNo 9'
(have read the havar�'ous materials requirements under Chapter 6.95 of BOMERCOMP(OVER 100,000 BTU) -
the California Health&Safety Code,Sections 25505,25533 and 25534. 1 �AV.�
unders Hf the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT BeREa/
r onsibility toffy the occupant of the requirements which must be met r
riortotsuance .C( rtifiate of panty. _ (�ay.�
O r,,r.r rivedagent Date - - ctrl ISSUEDBY: VO
TOTAL: `•'l
OFFICE COPY