21920APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
BuildingAddress:
- PERMIT NO.
^aE 920
G I G
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICALPLUMBING-MECHANICAL
N°: -
1T
CATEGORY -
CONTROL M
Architect/Engineer: Lk. No:
1&?Y ': '�fiLECTRIC PER1NtT IC. FEES'.-
'
- BUILDING PERMIT INFO.PLUMB
Address: \� ` - {�
PERMITISSUANCE
mjX:Fl
❑ ❑ -
-
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrm that I am licensed under provisions of Chapter 9(cortunane.
Ingwith Sedkm7000)m Divislon3 ofthe BusinessandProfesslonsCode, and my
license le in f d affect .� 1 e••�
Llrery:eC�Lk.p 4'`r'
Date a_ Contractor ._�"(�I f'(`}•
ARCHITECTS DECLA ON
I understand my plans shall be used as public records. -
Licensed Prdenslmrml
OWNER -BUILDER DECLARATION
Iherebyaffirmtlist I am exempt from the Contractor's Llrense Law for the
following Mason. (Section 7031.5,Business and Professions Code: Any city or
county which requires a permit t°ronstruct, alter, Improve, demollsh, or repair
any sticture prior to its issuance also requires the applicant for such permit to
file a signed statement that he Is limmed pursuant to the provisions of the
ct
Contraors Liceuee law(Chapter 9(commencing with Section 7000) of Divi-
Bion 3 ofthe Business and Professions Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjectsthe applicant to a avll penalty of not morethan
five hundred dollars ($500).
F1 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure la not intended or offered for
sale (Sec. 7094, Business and Professimn; Code: The Contractor's License law
does not apply to an owner of property who builds or improves thereon, and
who does such work himself orthrough his own employees, provided that such
improvements arenot Intended oroffered for sale, If, however, the building or
Improvement is sold within one yearofcompletion, the owner-buBderwill have
thekurden'of proving that he did not build or improve for purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed
to construct the project (Sec. 7614, Business and Professlom Code:
The Contractor's Lirense Law does not apply to an owner of property who
build. or improves thereon, and who contracts for such ptojects with a
uBACK0tt chats) hensed pursuant to the Contractor's License Law.
LU I am exempt under sec. B & P C for this reasnn
-
APPLIANCES -RESIDENTIAL -
PANELS
UP TO 200AW5
_JOB DESCRDa710N
-
2(I]-1000AMPS
OVER 1000 AMPS
- SQ. FT. FLOOR AREA
IN
E D
U T E R
I
r•V' I
$/SQ. Fr.
'
SIGNSELECTRICAL Al A
SPECIAL CIRCUIT/MISC
g7MMp METERORI'OLE INSr.
POWER DEVICES/'
SWIMMING IDOL ELECTRIC -
.VALUATION
p
OUTLETS5WITCHESFIXTURES
NEW RESIDENTIAL ELEGTR SQ.FT
STORIES
TYPE CONSTRUCTION
7pgAl:
,
Q'Fy, :''. �. PL(Jiy]$[(cJ (x'iPERMITy ;''FEE,i,'.'
ppgMCf ISSUANCE
ALTER -DRAIN &VENT -
WATER (EA)
OCC. GROUP
RES. UNITS
FIgDDZONE
APN
FLOWI'ROTFLT. DEVICE
.FEE,$UMMgRY(.'
-
Owner -Date -
DRAINSFLOOA ROOF, AREA, COND.
FIXTTIRES PER TRAP -
SANITARY Y_ N_
RECEIPT,
DECLARATION
WORK MAN Chase a certificate
I hereby affirm that I have a certificate of consent m self-themo ora
rt (Irate ofWorkers'Com/pesreatlonlrisurance oracertifled copy thereof (Sec.
Cron lab 14��
Poilry
Com q_
edified copy is hereby ted._
edified copy I. filed withh the the city Inspection divlslori., -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
E
(I'hlseeRlon need not be completedpermit later one hundred dollars
($100)orless6
Icenotrtify that In the person in an ]mannerhe work for which ,,dmahis permitsect to the
I shall not employ any person in any manner m as to become subject to the
Compensation laws of California. Date
W Applicant
Appllrant
NOTICETO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers Compensation provisions ofthe Labor
Code, you =at forthwith comply with such Immisloni orlMa permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lendingagenry for the perform
ance of the work for which this permit is Issued &c. 3097, Civ. C.)
Lender'.Nd. dr
f.encar'sAthatl
I rertlfythat] have read thbapplirationand datethattheabove Informal)
la correct.]agreeto comply with elldtyand countyordBut ncereand date laws
relating to building cons[ruction, and hereby authorize representatives of this
city to enter u Pon the above-mentioned property for inspection purposes.
- (We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments,mdsand expense. which may In any way accrue
agar sa, City in consequence the granting of this permit.
U p � I
SCITOOL TAX Y_ N_
RECEIPT I
GAS,EA SYSTFMIINC.90ITILElS
PARKFEE Y N
-
RECEI'TpVER4(EA)
S
GAEA. SYSTEM -OVER
GREASE/INDUSTRL WASTE INTERCEPTOR
- BUILDING DIVISION FEES
PLANCHECK FEE
PAID .
Date ReC i t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 20OFT.
- WATER HEATER W/VENT/ELECTR
GYFEE Y N —
:PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RE9DENTIALPLMB. SQ.FT,
TOTAL:
IL CAFE
- - TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. '- - MECHANIGAL'P�RMIT ` `"'-°'-TEE-`:;
PLUMBING FEE - -
PERMITISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL PEE
FEES PAID:
Date Receipt#
SUBTOTAL:
AIR HANDLINGUNIT (OVER 10,000CFM)
CONSTRUCTION TAX
s gn a of ppllcare/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
illtheapplicantorfuture building occupant store or handle hazardousHEATING
mated.) as deffnedbythe Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)I •
❑ Yes Ij No .
Will the applicant orfuture building occupant use equipment or devices
which emit haaa minus air contaminants as defined by the Bay Area Air,
Quality Ma nagement D❑istrict? -
4 Yea N No
have read the baza nus materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 255115, 25533 and 25539. I
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be mct
prior to issuance of a Certificate of Occupancy.
EXHAusTHDDD (w/Duan '
-
CONSTRUCTION TAX PAID:
UNIT (TO 100,000 BTU)
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
'
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
sI ,a ��
M 1 J
ISSUED �� of
B :
BOILER -COMP OFF OR 100,0(IO BTU)
BOILER-COMP(OVIR 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authorized agent -Date. '
Tnrac:
OFFICE COPY