20823APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Building Address:
PERMIT NO.
20823_ 0 n f'�
G }V(G �S!
e e sine: one:
II -IAL AIL
z,rj —
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
�� /lO
Contraear's Name: LIc. No:
�—
BUILDING- E.ECTWCA4I'LUMBINGMFLHANICAL
CATEGORY
CO
9'Ty
Architect/Engineer. Lk. No:
Qn ELECTRICPERMIT FEE
BUILDIN2 PERMIT INFO_
Address:
^' 11e—I
Krx
PERMITISSUANCE (e}d
LICENSED CONTRACFOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapmr 9(commm
Ingwith&dton7000)of Dlvlslon3ofthe Buslnessand Pmfnstons Code, and my
Lienee lslafuLL farce and effect.
License Claas Lica
APPLIANCErff4
PANELS
JOB DOSCRIPjION
/
Date Contractor
ARCHITECTS DECLARATION
I understand my plaru shag be used u public record&
201-1000 AMPS
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
S/SQ. FT.
TE
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
mm
I hereby afOrthat I aexempt from the Contractor's License Law fon the
cmntingreasoqui ctioe7 tt,B.i d, It.r, fpmve, Code Mycityor
countywhlch requlrcsa permit trcrrutvct, alter, bnprove, demollah,orrcpalr
(�(I
sa 'q O !
3�
�fq,,q
• / a
SPFLIALCIRCUIT/MIST
TEMP. METER OR POLE INST.
anystmaumpdortoitslasuame,aLsorequimstheappllvant(mauchpermltto
(Ile a signed statement the he to licensed pursuant to the provisions of the
Cceindole Lice. Lav, (Chapter 9(commencing with Section 7000) of Divi-
am%3 of the Businessens ProfeadmuCoae) mthat he b exempt therefromand
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant (Ora permit subjectathe applicant to a civil Family of not room than
five hundred dollars (5566).
Les owner of the pmperty, or my employees with wages as their sole
POWER DEVICES
SWIMMING POOL ELECTRIC
rLizilOUTLETSSN7TCHESFIXTURFS I'll Q
VALUATION
6Z17-90 Q' �) a O
6 op(
NEW RESIDENTIAL ELECTR _SQ.FT.
STORIES
TYPECONS'TRUCTION
compensation, will do the work and the structure ie not Intended or offered for
silo (Sec 7044, Business and Pmfeasion Cade: The Contractola Lt.. law
TOTAL: �s Q
docs not apply to an owner of property who builds or improves t hereon, and
who doeesuch work himself orthrough his own employees, provided that such
improvements are not intended reoffered for sale. If, however, thebulldingor
improvement b sold within omyearo(completion, the owner -build erwill have
OCC. GROUT'
RES. UNITS
e enof proving that he did not build or Improve for purpose of sale).
of the property, am exclusively contracting with licensed
ore construct
ntractGm to ruct the project (Sec. 7006, Business bn and ProlessCode:
QTY. PLUMBING PERMIT FEE
I PERMIT ISSUANCE ' •y m
FLOOD ZONE
APN
Contractors License law don not apply to an owner of property who
builds or improve thereon, and who contracts for such pippets with a%
��tr+ctor(s) licensed pursuant to the Contractor's Llrenss Law.
L_J I em exempt under Sec B k P C for this reason
ALTER -DRAIN k VENT - WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
FLOOR ROOF, AREA, COND.
FDn URNS PER TRAP
a ��!
SANITARY Y N
RECRUIT F
OwnerDRAINS
Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, or a
certlBrneofWorkero'Compewtlon Gouranmoraceftlfled copythemaf($ec.
3800, Lab C.)
SCHOOL TAX Y N
RECEIPT I
1 GAS FA SYSTEM -I WC1OVIlE'f5 "L e(�
l
PARK FEE Y N
PolCffi
RECEIPT
Cam any
GAS EA. SYSTEM -OVER 4 (EA)
OfV
BUILDING DI VISION FEES
�Ceti[Red ropy b hereby th the city
Ceti [Red mpylallled with the city WpecHon division. -
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCH
GREASE TRA
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PAID 7
COMPENSATION INSURANCE
(This section need not be completed if the pemdt inionone hundred dollars
Date
SEWER -SANITARY STORM EA 71mr1'
($100)orlessJ
Icenoy thein an person ance
not employ any person In any manner ao as to become subject to the
tmannerhe work wastobecomforwhich this esubjrmit is bo the
I Workers
W plican Compensation laws of Glifomla. Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you
should becomeeub)ect tathe Woke.-Compewtioo provlaimuof the Labor
Code, you must forthwith comply with such provisions orthla permit shall be
deened revoked.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y _ N
PAID 7 {, �g
Dae Recei tg •MCI
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB._SQ,FT.
TOTAL: %g-•
FE6 S0 I
_BUILDING
SEISMIC
CONSTRUCTION LENDING AGENCY
Iherebya(llron that there is a contraction lending agency far the perform-
arm of the work for which this permit is Weed (Sec. 3097, C]v.CJ
TOTAL: • Qi
ELECTRIC FEE O
�'
Mindere Name
sander's Addams
I certlfylhat I have readthb appllatlonaM Rate that theabove Infornution
la current l agree to comply withal] city and county ordinances and state laws
QTY. MECHANICAL PERMIT FEE
( PERMIT ISSUANCE Zea
PLUMBING FEE Oen
MECHANICAL FEE
FEE$PAID.
minting to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agaWtliabl ties, judgments, meta dexpen w any wayamue
against sal yin ronsequence t egrantin (this permit.
Iy Q1
`
Date Refel IN
ALTER OR ADD TO MEC H.
AIR HANDLING UNIT 0010,000 CFM)
SUBTOTAL:
AIRHANDWNG UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
Igruture of Appllaat/Contrelor I Date
E(HAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALSDISCLOSURE
I HEATING UMT(TOIRR0006TU)
WllltheappBrznt or future building occupant store or handle haaardous
materleaede(ined by the Cupertino Municipal Code, Chapter9.IZ and the
Date Reeel tR
HEATING UNIT (OVER 100,000 BTU)
TOTAL: 3,1
Health aM Safety Code Session 25532(e)?
❑ Yes No
Wllltheappllcant'Plume building occupant use equipment or devices
which emit havrdous air contamina nts as defined by the Bay Area Air
Quality Management District?
Yes ❑❑ No
have read the F anrdous malerlab requirements under Chapler8.95 of
VENTILATION FAN (SINGLE RESID) L1
1
ISSUANCE DATE
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVLR 100,000 BTU)
the California Health k Safety Code, Sections 2SS05, 75573 and 25534. I
NEW RESIDENTIAL MECH. SQ.FT.
understand that lithe building does not currently hnveatenant, that It Lsmy
rmponelailityto notify the occupant of the requirements which mustbemet
prior to issuance of a Certificate of Occupancy.
ISSUED QUYI �i�
Ownerorauthorlud gnt Data
TOTAL:
OFFICE COPY