20446APPLICANT TO FILL IN INFORMATION WITHIN REDLINES —USE BALL POINT PEN ONLY -
Building Pro'en Identification
Building Addres„
/038
PERMIT NO.
20446_
els ams. o one:
9/ _
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CITY OF CUPERTIN6BUILDING DIVISION
APPLICATION / PERMIT
BNLDING-ELECTRICAL-MUMBINGMECHAMCAL
A ,
D rT
(;mtka Rm'sNo LIc. No:
7104:5
CA=RY
Architect/Engineer. - .• LIc. No:
QIY ELKTRICPERMIT FEE
BUILDING PERMITINFO
Address ZZ52 1z4
PLUMB 101�11
s9�
PEFMTISSUANCE ZW
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflren that l am licensed under provisions of Chapter9(comment
APPLIANCESRESIDENTIAL
JOBDFSCRIPIION
PANELS
-
IngwithSedion7000)of Dleislon3oftheBusinessand ProfessionsCod,andmy
license Is in full fora and effect.
License C6aC--_ Lk.N 27
�..•,..
Date Contractor'.80.SZ GaiafY_ � 1UPTOMAMPS
ARCHITECTS DECLARATION
I understand my plans shall Wooed as public rcmrds.
mi-1000AMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed l'mfesvlanal
SPECIALCIRCUIT/MISC'
OWNER -BUILDER DECLARATION
Iherebyafllrm that lam exempt from the Contractor's License Law for the
following reason.(sceron 7071.5, Business and Professions Code: Any city or'(A{P.METLR
muntywhich require a permit to matruci, alter, Improve, demolkh,orrepair
' '
OR POLE INST.
anystrurnme prior to Its Woo me, a he requires the a pplicant for such permit to
file a signed statement that h< 6lkensed pursuan o the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
a+a•�
OUTLETSSWITCHESHXTUR 11 -2 t.a/
Jt
Cc trader's License Law (Chapter (rommendn Ith Benton 7000)o(Dlel-
sion3of the Ouainese and ProfealoaCode)arch he6exempt thcre(romantl
the basis for the alleged exemption. Any vio ton of Section 7031.5 by any
appliantforaper twbjenstheappticantt advil penalty of net more than
VALUATION -
�a �00��
NEWRESIDENTIALELECTR a
' '�'
five hundred dollars (650(n.
❑I, as owner of the Property, or my ployess with wages as their sok
compensation,wllldothework.andth trunurebrotintendedorofferedfor
STORIES
TYPE CONSTRLCTION
...(Sec. 7044, Businessand Profess) Code:Ths C.re.ciols Llmrxr Law
does not apply to an owner of prop who builds or improves thereon, and
who doessuchwork himself orth gh hisownemployees, provided that such
improventrosare not Intended rofferedfmr le.ILhowevegthebuildingor
improeernentiswldwlthinon arofcomplMlon.theowner-buBderwlllhave
t,C*rdenaf Freeing that didnmt ildorlmpmveforpurpmeofwk.).
u I, as owner o(the party, am exclusively contracting with Ilmnxd
contractors to mmtivn projeci(Sec. 7064, Business and Professions Code:
,
! �
,.00C. GROUP
RES. UNI TS
jpFAL: 6
QTY. P ! G.PERIwT FEE
FLOOD ZONE
.
APN
PERMIT - ANCE d' e1
G 4
The Contractor's Lim Law docs not apply to on owner of properly who
builds or Improves hereon, and who rontrans for such plopcte with a'
ytt dor(s) licensed pursuant to the Contractor's Limn:Law.
cUl am exempt under Sec. B & P C for this masonOUTSIDE
ALTER IN & VENT.- WA a
FEE SUMMARY
_ r�
BACK FLOW PROT� µW
FEES
DRAINS * IR ROO
SANITARY RECEIPT Y
Owner Date
WORKMAN COMPENSATION DECLARATIONFIX
❑1 hereby afflmn'that I have a certificate of consent to self -Insure, or
wnlfinteofWorkers'Compemationlrouranmoracertl0ed ropythemof(See.
380D, Lab C.)
�^_ rf moi /
SCHOOL TAX Y_ N
RECEIPT R
GAS .SYSTEM-1OUTLETS 1.(fD
PARK FEE Y_ N_
RECER'T R
Policy 0 /. p Dai
Coany
GA. SYSEE(A
BUILDING DIVISION
Certified copy 6 hereby furnlshed.
rrcrtifed copy 6 filed with the city Inspection division.
!LJ
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
ICREASETRAP -
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(Missed ion need not be comZ melt 6 for one hu od red dollars
PAID
Date RCCCI iii
s�(''�a�s
U7lw
SEWER -SANITARY -STORM FA.XpF 1'.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
-
($100)0rless.)
Icertllythatinthepedorma'.forwNch thio permitb6iued,
WATTR SYSTEM/TREATING 2l
I shall not employ any perwn toso a to beromia subject to the
Workeri Compensation Lawsome
Applicant '
NOTICE TO APPLICANT: after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
PAID ' '
Date Recd t4f
Yc�
NEW RESIDENTIAL PLMB. SQ.FT.
'
TOTAL:
-
BUILDING FEE
Code, you most forthwith comply with such prov6loa or this prmo t shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
ISO
Ihereby affirm that there is a construction kndingagenty fortheperiorm
ante of the work for wldF m iaissued(Sce. 3097, Ci,,. Q
Lender's Name 1 / !7-
LendeJsAddreas
Imrtifythatl havemadth6apphcatbnandrtatethattheaboveinformation
bmrrM. IagreetocamplywithaHdtyandmuntyoNianmandmatelaws
TOTAL:
`
ELECTRIC FEE
ELECTRIC EEE
asrt
l�
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
ez,-2.CiJ
- iT .w
PERMITISSUANCE .(�s.-t/
-
FEES PAID:
relating to building coatrunlon, and hereby euthoriu representatives of this
city to enter upon the above�mcntioned property for Inspection purposes.
' (We) agree to save, Indemnify and keep harmless the City of CupertinoDate
against liabilities, Iudgmnts, costs and expenses which may lnany wayacaue
- ALTERORADDTOMECH.
Receipt#
AIR HANDLING UNIT(TD10,OOO CFM)
SUBTOTAL:
against said City In consequence of granting of this permit -
AIR HANDLING UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor -' Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
HEATING UMT(TO 100,00 BTU)
Date Recei t#
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Ikalth and Safety Code�Se 25532(a)?
❑ Yes LI�'N
� or devices
Will the applliant or foto building occupant use equipment or
HEATING UNIT (OVER 100,000 BTU) Q((�
TOTAL:
C
PAN( SINGLE RFSID)
1$$UAI�.�ATE
which emit havardoa airmnta anHade0ned bythe Bay Area Air
Quality Management Dist
4 Yes No
havereadthchuar omaterials requirements under Chapter 6.95 of
the California I lealth & Safety Code, Sections 25505, Z5S33 and 25534. 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 reset
S'
(- ('�❑(�
O V 199A
JVI
�
!`:4/ VI CUQCIM
BOILER -COMP DEIPDft 100,000 BTU)
BOILER-COMP(OVER100,00O13'11J)
NEW RESIDENTIAL MECH. SQ.FT.
prior to ante of a rtificaloof Occupancy.
ISSUT:D BY:
Ow ror authorireda est
Date
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a�
TOTAL: 2^
OFFICE COPY