20860APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: s
R.
PFiitMHE NO.
1O8O
20860
7 one:
sera anr: 7,32--5-79,5
Lz,S�.1E /32: 5-79 j
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
BUILDINGELECTRICA4PLUMBINGMECHANICAL
A A A
c°nt�e—dp�s°N�s"na: LI= Na:�
CYrT ///Pr'S4/`Ia�jetx—1
CATE=Y
CONTROLM
Architect/Engineer. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:��i
PQtAfITI55UANCE
ITEMS MMI
1:1 ❑ El
CONTRACTOR'S DECLARATION
Ihereby affirm, that l am licensed under pro evon° of Chapter 9(mmmenc.
ingwithSmbn7O00)of DiAslon3ofthe Businessand Prof¢mlonsCode, and my
Ltan., b In fuR (o d dreat.
License Class�('y_. Lt. It
APPLIANCESREMDENTIAL
JOB DESCRIPTION
PANELS
Dated 1 /_Fq%_contractor a!
ARCHITECT'S DECLARATION
I understand my plass shall be used as public records.
2014000 AMPS
OVER IOW AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor: License Law for the
SPECWLCIItCU1T/M
TEMP METERORPOL
ppy�g DEVICES
following reason. (Section 2031.5, Business and Professions Code: Any city or
county which mquiresa pernottocoromact, site, Improve, demolish, orrepalr
anystmmmpriortoitsusuance,ahomqulrestheappRoAtforsuchpermitto
file a signed statement that he le licensed pursuant to the provblora of the
Contractor's License Law (Chapter 9 (commencing with Section 2000) of Divi.
sion3olthe Business and Prefeaslom Code)orthat he b exemp4therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicantforapermitmbiec theappllcanttoadvllpewltyanotmorethan
live hundred dollars ($500).
I, as owner of the property, or my employees with wages as their wie
compensation, wllldothe work andthestructure Is not Intended or offered for
SWIrtMIN L C
VALUATION
OUTLETS XTURES
NEW RESID LFLTR
STOW FS
TYPE CONSTRUCTION
sale (Sec. 7044, Business and Professloss Code: The Contractors License Law
docs not apply to an owner ofproperty who Wilds or improve thereon, and
who does such work himself orthrough his own employees, provided that such
Improvements are not Intended oroffamd for sale. IL however,thebuilding or
Impnevemant la sold within oneyearaf completion, the owner -builder will have
t rdea of proving that he did not build or improve for purpose ofsals.).
L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7054, Business and Profesalotu Cade:
The Contractors License Law does not apply to an owner of property who
Wilds or Improves therms, and who contracts for such ptojecs with a
c9atfadm(s) homsed pursuant to the Contractor: Llave Law.
U I am exempt under Sec B & P C for this reason
OTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WA (EA)
OCC.CROUP
RFS, UNRS
ET-OOD20NE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE ELES
Date
DRAINS. FLOOR ROOF, AREA, COND.
FIR711R11S PER TRAP
SANITARY Y_ N
RECEIPT p
WORKMAN COMPENSATION DECLARATION
I hereby afrim, that I have a cendloste of consent to seR-Insure, or a
=rtiflcate of Workeri Cemp msatlon Issurance ora certified copythemof (Sec.
3500, Lab
SCIdOOL TAX Y N
RECEIPT N
GAEA.YTM-1 INCA
PFEE YPolicyp N_
RECEIPT a
Co y yam`—A — —
Certified copy is hereby tarnished.
Certified copy la filed with Ninspection city dlvlslon.
S
GAEA. SYSTEM-0VER4(EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FE
PLANCHECK FEE
CS
GREASE7RAP
CERTIFICATE OF EXTIFEION FROM WORKERS'
COMPENSATION INSURANCE
(1'hiasectlon need not be completed lfthepermlt bformahundreddollars
(SlWsmless.)
1 ll not that o theparperformance i of the wok fo as to b co permit Is tailed,
1 shall not employ any person in any manner at ss to become subject to the
Worked Compensation lawn al Call(omla. Data
Applicant
PAID
Date Revel t#
SEWER -SANITARY -STORM EA. 200FT.
WATER MATER W/VENT/ELECTR
ENERGYFEE Y N_
PAID
WATER SYShM/TREATING
NEW RESIDENTIAL PLMB._SQRE
NOTICE TO APPLICANT: If after making this Certificate of Exempt to you
should become subject to the Workers'Compevatlon provisions the Labor
Code, you must forthwith comply with such Provisions, orchis permit shall W
deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a mrstrudion lending agency for the perform
anceof the work for which this permit is Issued (Ser. 3097, Civ. Q
lender° Name
Lender's Address
I certify that I lave read this appRcatlon and state that the above infamuNon
brorred. I ugreeto comply with all city and county ordinances and state laws
relating to building mmtrudlon, and hereby authadze representatives of this
dty to enter upon the abov nnrntlorad property for inspection purposes.
MPU agoy�t)) vat W lead y an d ke/ p harMess the City o! Cupertino
against llaJN !III judgme ost dei pensee which mayin anywayaarue
agairyst sal tlLLy in cony eor canting a this pemuc
Date Remi til
TOTAL:
BUILDING FEE
TOTAL:
SEISMIC FEE
ELECTRIC FEE
4
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTER OR ADD TO MUCH.
AIR HANDLING UNIT ITO IO,ODOCFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,WOCFM)
CONSTRUCTION TAX
ySI _ _ �.Q
!l
Slgrat e0 Applicant Contr or Data
NA2lARDO SMA IALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
I
Q Yesd Safety Code,seNo n 25532(a)7
E%HAUS'THODD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
HEATING UNIT (OVER 1 Wp00 BTUI
TOTAL:
//
4 LSQ
Will the applica future building ocmpant use equipncnt or devices
which emit havardous air conts mint. as cie0ned by the Bay Area AU
Qu Illy Mawgentent rid?
VENOLATIONFAN (SINGLE RESIDE
I$$U CE DATE
NC'®
BOILER -COMP OHI' OR 100,000 BTUI
4Yes
have read the hazy ousmateda6 requircmenbunderChapter 6.95 o!
the California Health&Safety Code, Sections 255O5,25533 and 25534. I
undersW atifthe Wildingdoesno rrentlyhaveamnanLthatitkmy
respo Bi mnotify the t the requirements which must be co=t
Prior to once ofa'ate panry. qq
V
AUG r/��rxo
H ! y
City Of
BOILER CONP(OVER 100,000 BTU)
NEW RESIDENTIAL MECIE SQ.FT.
ro authorized age Data
s
ISSUED BY:
TOTAL:
OFFICE COPY