20800 ANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
uuildin Project Identification J -27 PERIMIT NO.
Z s=: �rG, ci -1 _�PE �►moo c� 20800
one. AITLICArIONSUBMIIIALDAIIE
tJ�. �S r5T'AC CITY OF CUPERTINO-BUILDINC DIVISION40
Name: _ 7 Lie.No; APPLICATION I PERMIT
N C'J BLTLOIN'GELECTRTCAL-PLUMIBI.NGMECHANICAL CATEGORY CONTROL N
. ..!Engineer. Lk.No:
— - - QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE I ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby af(um that[am licensed underproviiom of Cfia)rter9(commenc- APPLIANCESRFS7DENTIAL � JOB DESCIiII'fiOh'
inenseI in fonforce of Di effect ofthe BusinessandPro(essionaCode,and my ���
license is in full fame and effect. PANELS
License Class Liep
Date Contractor UP TO 2N AMPS
nc AACHITECI'S DECLARATION 201.1030AMP9
HOZ I understand my psnsshallbe used as public records, OVERIXQAMPS `SQ.IT FLOOR AREA 3/SQ.FF.
OnseSIGNS ELECTRICAL
b U V Liced Professiowl
%w OWNER-HUILDER DECLARATION %
in:3L IherebyafiTrmt hat l am exemptfrom the Contractor's License law for the SPECWLCBiCWT/MNLSC _
?O following reasor.(Secoon 7031.5,Business and Professions Code:Any cry or TEMP.M EfER OR POLE INST.
,.Lt_ county which requires a permit to construct,alter,Improve,demallsh,or repair
e1$= anystwctum priorto its issuance,also requiresthe applicant for such per 'to POWER DEVICES
C J file a signed statement that he u licensed pursuant to the provi ions of the
5� Contractor's Licenselsw(Chapter9(commencing with Section:000)o(Divi- SWIMMING POOL ELECTRIC
O c'✓ VALUATION
C< sion3ofihe Business and Pro(essiov Code) hei exempt ,
the bass for the alleged exemption. Any violation of Section]031.5 by any OUILETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not mocthan
L e h red dollars(55M). NEW RESIDEU77ACELECTR SQ.FC. SI'OIIIES TYPE CONSTRUCTION
2S i,as owner of the property,or my employees with wages as their sole
kzi mponsation,willdothework and thestrocture snot intended or offered for t, I• ,\I
FC sale(Scc.9Wa,Business and Profession Code:The Contractors License Law -
,'•c+//7i does not apply to an owner of property who builds or improves thereon,and - f txC CROl11s RIS.GNITS
who doessuchwork himself orthrough hisuwreempioyees,provided that such
Improvements are not intended proffered for sale.1(howeverthe building or :-70TAL: .
improvement sold withinoneyearofcompintion,the owner-buiiderwill have `a
the harden of proving that he did not build or improve for purpose o(sa4J. QTY. PLUMING PERMIT X�s-'MFEE FLOOD ZONE APN
nL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE'1 t
contractors to construct the pmjea(Sc.7044,Business and Professions Code:
The Contreaor's License law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such prpjero with a ALTQLDRAIN&VENT-WATER(EA)
contnator(s)licensed pu ant to the eono-actor's License Law. FEE SUMMARY.).
❑( am exempt u de Sue. B 6 P C t r thi m BACK FL IOW PROTECT' MV E_ OUTSIDE
n a — "- ' T m DR/ M1'S FLOOR ROOF,AREA COM1�'D. SANITARY Y N
Owner L Date - RECE117 N
WORIC\IAN COMPENSATION DECLAR ON S/ �1 SCHOOL TAX Y_ N_
❑I hereby affirm that 1 Fave a cenifkate of consent to seiGinwre,ora t RECEIPT N
380certificate
GWorkeri Compensation Insurance ora cemfied copy thereof(Sec. GAS-EA.SYSTEM-1 INCA
Q PARK FEE Y_ N_
RECEIF`F N
PoliCamryaey GAS �GWiM � I BUILDINGDIVISIONFEES
�Cenified cop"hereby tumished. GREASE/LNDUSIRL WASTE INTERCEPTOR r PLANCHECK FEE
nCenified copy s tiled with the city inspection division.
CERTIHC%n OF EX MI'TION FROM WORKERS' CREASE TIZNP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STOILM EA 300FT Date Recei Pt#
(1'hlssection need not be completed if the permits for one hundred dollars
(5100)onessJ WATER HEATER w/vENr/aLCTa ENERGYFEE Y_ N_
1 cenify that In the peformarece,of the work for which this permit is Swed,
1 shall not employ any person in any manner so as to become wbjeet to the WATER SYSTEM/TREATING
Woeken'Compcmatioo Lawsof Cailfoms. Date PAID
O n scant Date Recti t#
Z Z NOTICE TO APPLICANT:If,after making this CertBloteof Faremption,you NEW RESIDENTIAL PCMB. SQFI'.
p2 should became Compensation to the Workers Competion provisions ofthe Labor TOTAL:
C W Code,you most forthwith comply with such proviiores orthis permit shall be BUIL TNG FLE CX1
deemed revolted.W m
CONSTRUCTION LENDING AGENCY SEISM
E IC FEC' O
d O Ihereb mrmtluet there i a construction lending a forthe rforce, ELECTRIC FEE
ya . agency pe TOTAL:
0 Z ante of the week for which the permit iswed(Sec.3097,CIv.C.) PLUMBING FEE
02 Ienderi Name
U. I= Lenders Addmsa QTY. MECHANICAL PERMIT' ' FEE MECHANICAL FEE
U Tceit. that I Nate,to e mad I comply sth allcityna red gate dcounyordinancus the and
FEES PAID:
O W is<orrect.legreencomply with all city and county ordinances and state laws PERMIT ISSUANCE
�} 1 relating to building construction,and hereby authorize mpresentativn of this
Z city to enterupme the above-mentioned property for Lupeaion purposes. ALTER OR ADD TO MECH.
(We)agree to vve,indemnify an d keep harmless the City or Cupenlno Date RCeeiPtp
V against liabilities,judgments oma andexpvreeswhlch may in anywayaccrue AIR HANDLING UNIT(TO I0,G90CFM) SUBTOTAL:
a Aran 'tv in ceo(the an tiogofthispinnn
AIRHANDLING LT\Tr(OVER la,aoacFM) CONSTRUCTION TAX
sgna Appu am Exw\Lsr HooD(w/Dern CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
occupantWill the applicant or future building occupant storeorhandlehazardous HEATING UNIT(TO IDgW
000 BT _ Date RCCCI tic _
material as defined by the Cupertino Municipal Code,Cfiapter9.13,and the
Health and S,fetycodeion 25532(a)?a)? Fib\TING UM17T(OFR 7W TOTAL:
V00,000 BTx�
I.
Oilll the epplkfutu
an rrc buoc
ilding cupantse uI uip—.t or devices VENR -
LATION FAN(SINGLE RPs1D) ISt UA DATE
which emit ha.rdous air contaminrits as ddlned bvthe Bay Area Air -
O Ety Marugement RetrialFIR-COMP(BHPOR 100,MIWTM
4Yes o
havc,mtd the haxara s rwtenals rcopineuvots underChopter 6.95 of BOILLR-Coml,(OVfR 1 now 111u)
rhe California Health h Stfey Cudc,Seaioru 25505.1-3533 and 23531. I
understand that if the Building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.I7.1
ns pons ibiIity to nuifvth occupant oft heruquirementsw 'ch musr be met Lil� :I („!Bk?f illll}
'no
cc n icae of Ocmpanty.
Ownerorathonved age �Da�— ICTAL: !SSCGD By:
OFF'('E COPY