20283APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pm'ect Identification
Building Address:
40F37-3 wR
PERMIT NO.
' 20283
nese arse: _ one.
APPIICATI=p p
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
ii1LDINGELECTRICAL-MU BING-MECF LAICAL
S -
co t ador'aN Llc. No:
N 0
CATEGORY
CONTROLS
rehitaat/Engineer. Llc. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PERMITISSUANCE
w y ❑ ❑ ❑
�iJC
Slew
Lmthat EUCO Aunderp D ns ofChON
I hemby affirmlhatfam licensed underp Ions afCssions9(commenc-
inenseI In
000) andeffeon3 ofthe Bu essandPro(esslomCade, and my
license Isla toll( and c.0 ��
Llano Cla Lic.p ��
APPLIANCFSRESIDENTIAL
PANES
JOB DESCRIPTION
Date Contractor
LIP TO 21KAWS
70I-1000 AMPS
ARCHITECT. L
Ion erstand my plans shall be used as public records.
OVER 1000AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELEC AL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fmm the Contractor's License Law for the
following reason.(Sedan 70315, Buslnev and Profenlana Code:Anydtyor
M
countywhich rcquimsa perttocomteact, alter, Improve, demoibh, ormpair
any structure prior to its Issuance, also requires the applicant for such permit to
file a signed Statement that he Iv licensed pursuant to the provialore of the
Contractor's License law (Chapter9 (commencing with Section 7000) of Divi-
sion3ofthe Bustnessand ProfealoruCcolOmIlte he is exempttherefromand
on 70315 re any
the bash for the alleged sects th on. Any violation of penalty
applicant for a permit subjects the appllcantto a civil pevlty o(not more than
five hundred delta. ($500).
1, as owner of the property, or my employees with wage as their sole
compensation, will do the work and the structure IS not Intended or offered for
SPECIALC NT/M
E, EINSf. t
DE1�
NG
EL
C
VALUATION
O ���
O ETS ti ;!r
-
E• SQ'FT
W STOFS
TYPE CONSTRUCTION
Sale (Sec. 7064, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon,and
whodoessuchworkhimulforth augh hisownemployas, provided thatsuch
(
OCC.GR011P
RES. UNITS
Improvements arc not Intended oroffered formic. If, howeveq thebullding or
Improvement Bold within one yearofcompleliom the owner-bullderwill have
t"mien of proving that he did not build or improve for purpose ofv4.).
u I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7064, Business and Professore Cade:
The Contractor's License Law does not apply to an owner d property who
Wilds or Improves thereon, and who contracts for Such ptojects with a
ador(S)liamed pursuant to the Contractor's Llcenu Law.
I a
ell m exempt under Sec B by P C for thismason
TOTAL:
QTY, PLUMBING PERMIT FEEp(ppD7pNE
PERMITISSUANCE
ALTER -DRAW &VENT- WATER ffNN
WpN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
❑I here WORKMAN COMPENSATION DECLARATION
by affl. that I have a certificate of consent to self -insure, or a
arciBcate o(Worken'Compewtlon Wurance ora renified ropy therco((Sec.
3800. lab C.)_nSiYF��.
Policy p_
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
RECEIPT k
FIXTURES. PER TRAPBadOOL
GAS EA. SYSTEM -1 INC.4OUTLETS
TAX Y N
RECEIPT X
PARK FEE Y N
AECEI'f
Co; any
[rCrniB y turn R
�,C_nifiedcopybfiMdwitht city inspection division.
GAS EA. SYSTEd-OVER4(FA)
GREASE/WDUSIRL WASTE INTERCEPTOR
p
BUILDING DI VISION FEES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbuction need not be completed ifthe permit is for one hundred dollars
($10 renilyss.)
Ill not that lathe persean I any m,u work Sorwto cern peSubjecrmit is bated,
I shall not employ any person in any ani aer at ss to become subject m the
Workcan Compematlon Gwa of California. Date
Applicant
PAID
Date Recei tit
'
SEWER -SANITARY -STORM EA 700FT.
WATER HEATER W/VFNT/ELECTR
ENERGYFEE Y N
PAID
WATERSYSTFM/TREATING
NEW RESIDENTIAL PLMB. SQ,FT,
NOTICE TO APPLICANT-. If, after making this CertBlate of Exemptbn,you
should become subject to the Workers' Compemat Ion pmvisioru of the Labor
Coda you at forthwith amply with such Provbiore or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affi,morkf that there i a constructionISham lending agency for the perform,
arta erthe work (or which this permit b Lssued (Sec 3097, Clv. CJ
Iander's Name
Lander'sAddrru
I rerdfylhall have readthbapplicationand statethatme above Information
bcorrect. I agree to comply with all dtyand county ordinances and slate laws
relating to building coreteaction, and hereby authorize repremntetives of thb
dly to enter upon the above-mentimed property for inspection purposes,
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses Which may In any wayaccme
against Said City in consequence of the granting of this permit.
Date Recei t$
TOTAL:
BUILDING 'E
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMR ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
�_�9
Date "- ReCeiptif
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
{')$TOTAL•
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
bete
Signature o(Appll AZAR DOLS
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
CON;,'[RldTRW PAID:
GG11�1➢Y
HEATING UNIT (TO 100,000 BTI!)
Will the a ppllca nt or future building occupant store or ha nd le hazardous
reatedal as defined by the Cupertino Mu nicipa l Code, Chapter 9.1 7, and the
Stection 25537 (a)7
Health and Safety Codr�+-No
r-1 Yrs L
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
_I
Wllltheappilcant orfutom building occupant use equipment or To"
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dbtr(dT
Yes No
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
BOILFR-COMPOHPOR 100," BTU),
fhave,sdtheb rrr oue mater lab requirement under Ch rG95 of
.he Czliforn la IT Ithk Safety Co de, Sed lora 755M 25 San 36.1
understand ifthebuildingdoes notmrm.tlyh ate nt,thatitbmy
' it ' tondlfythe ottvpantoftheaqu nls ich must be men
P a nl fI t P.fompar
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
out atred agent to
f(�s. '• .
I/�T 4J\CJS
TOTAL: IS5UEDBY:_
OFFICE COPY