20618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Idemi(ka0on � ay_ PERMIT N20618
Building Address: q a I IDG-Ewtl �
0R . a
TM-7r".l7q.: one:
VIE IGAfz"r 1.5 5 - 414q CITY OF CUPERTINO-BUILDING DIVISION
c.n at raNam<: p r1- a f_ LIc.No: APPLICATION / PERMIT b
O m N -�.A W�7 O a BUILDING-ELECTRICAL PLUMBINGMECIIAMCAL CATEGORY CONTROL X
AreMtect/Engineer. Lle No:
QTY ELECTRIC PERMIT,,, FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 1::1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ao4mthat lamlken3ofthe under Wnmand Pro Chapter9de,and c APPLIANCESRFSTDENTIAL JOB DPSCRB'fION
ingwlth SecHon7000)of Dlvlaon3ofthegumneaand ProfeelonsCade,andm
Licamme.IsIryAB,t�cgyld c**. 1z/ 560 � PANELS C140-1Nr_>1 t7F Pad R
License Cl �'•-1 l0 '
Date Contractor
ARCHITECT'S DECLARATION 201-10DOAMPS
pkp�+v'mO pC ZI understand my plans,shag be used as public record& OVFR 10(10 AM SQ.FT.FLOOR AREA $/SQ.FT.
t9 U Licensed Pro(eeloral SIGNS ELECTRIC
<Zol
6 OWNER-BUILDER DECLARATION SPEC CIRCUI
t.., g Iherebyaffirentluitlamexempt fromthe Contractors LlmnseLwfor the
o following reason.{Section 7mIS,Buslnen and Pretreat...Code:An ci or
Fzt" cannlywhich requires a perret to construct,alter,Improve,demolsh,me,palr TEMP'
any awcture pdorto t that
he is licensed
pursuant to the provisions
of tm
(Ile a signed katement that he s Ilmnsed pursuant to the proNaloru of the POWER S
Ow Contractor.License Law(Chapter9(mmmeneingwith Section 7000)ofDivi-
�Og slon3ofthe Busineasand Prefembtu Code)orthat he Is exempt theerfromand SWP4MIN LELEGTRIG VALVA'ILON
Q ,the bass for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES , / O40 U
applicant fora permit subjects the applicant to a civil penalty of net more than
flue puns ed owner ars of the
p0). It NEW RESIDENTIAL ELECTR_SQ,. STO is TYPE CONSTRUCTION
�n ❑I,as owner.(the property,or my employees with wages as their cola
compensation,wiRdwhe work and themmeture is,nm Intended.,offered for
q sale(Sac 704E Bushieas and Professions Cade:The Contractors License law
[�js$ doe.not apply to an owner.(property who Wildsor improve thereon,and OCC.CROUP RIS,UNITS
who does such work himself orthrwgh his own employees,provided that such
lmprovemens arc not intended oraffered for sale.If,however thebullding or TOTAL:
Improvement sold withinoneycamfcomptdion,theowner-bu0derwOI have
tt1eJ)ureianotproving that he dldece build orlmprove for purpo.eofsale.). QTY. PLUMBING PERMIT- FEES FLOODMNE APN
Lj I,as owner of the property,am exclusively contracting with licensed
contractors to mrutruct the project(Sec.7044,Business and Protessl.w Code: PFRMITISSUANCE
The Contactors License Law does net apply to an owner of property who ALTER-DRAIN k VENTWATER(E/q
Wilds or Improve.therm., and who met far such Euejecv - -with a -
ado4s)LimnxdpursuanttotheCommerce'.LI...Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec. B k P C tar the ream.
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• Owner Date RECEIPT X
❑I hereWORKMAN COMPENSATION DECLARATION
by affirm that I have a mrtiRcate of convent to self-insure,or a FD('I'URES PER TRAP SCIIOOL TAX Y N
3800,lab abC.)o(Worken'Comperuatlon lnnuranreara carti(sd ropythereaf(Sec. RECEIPT X
GAS I EE EA.SYSTEMINCA PARK FY N
Policy p RFCFIGAS EA.SYSTEM-OVER 4(EA) 'T X
Com any BUILDING DIVISION Iii ES
Certified copy Is hereby te
Certified copy slued withh the city
inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCIIECK FEE
ty
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM PA.200FT. Date Recei t#
(rhlssection need not be completed If the perndt Liter one hundred dollars
(5100).H.) mce WATER HEATER W/VENT/F3.ECTR ENERGY FEE Y N
I camlythat m the perforanof thawmk forwhlch this permit is Issued,
I shall not employ any person in any manner m e to become.object to the WATDi SYSTCM/TREAITNG
Workem'Compenwtlon Lawsof Glifomla.Date PAID
z Z Applicant NE'WREADENTIALPLMB._SQFT. Date Recei t#
Z O NOTICETO APPLICANT:7f,after making the CcrtRlcale of Examptlon,you
Hshwld become subject to the Worker.'Comperwtlon prevsloro ofthe Labs TOTAL:
N Cade,you at forthwith comply wlthkch provslowor this per itsballbe
> deemed revoked. BUILDING FEE . co
W CONSTRUCTION LENDING AGENCY SEISMIC IEE
4. Ihembyaffirm that there s a construction leadingagency for the perform- TornL: ELECTRIC FEE
Z anceofthework(orwhlchths prrutstswetl(Sec.3097,Civ.CJ
U O lender.Name - PLUMBING FEE
LL t- Lender's Addecs. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cmtitythat l have read thb,applicationanci demthattheabovc lnforrtxtl.n
Is correct.I agrmto complywlth all city and county ordinances and mate laws PERMI'TISSUANCE FEES PAID: ,
} a relating to building construction,and hereby authorize representative ofths
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
V _ (Wa)agree to save,indemnity an d keep hareem the City of Cupertino Date Receipt#
against liabilities,judgments,mks and expenses which may In any way accrue AIRHANDLINGUNIT(rO 10,000 CFM) SUBTOTAL:
agaI teal tley ,quenm of the granting of this permit.
.4• 1 AIR HANDLING UNIT(OVER IEOW CFM) CONSTRUCTION TAX
Sigmrc
t 01 Applun/Contactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappliwnt or future building ocmpantstom or handle hazardous HEATING UNIT(TO 10(L000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Helth.cad Safety Code Section 255320)? HEATING UNIT(OVER 100,0(0 BM TOTAL: a
Ye No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cut hazvdous air contaunant.as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) CARKa
4Yea n No
ha ercadtheh mo us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ��^' s3 I['yU
the California Health A Safety Code,Sat torts 25505,25533 and 25534.1 T'1 Ga IJ
understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQFT.
eap.eMbilitytomalty theoccupant fthe requirementawhich mo at be met •. s
prior Ise ce of Ce ifiateolOmpanry. City OI C1�11P,(tIOO
2i 2-29'-e/ ``--
Own ror authokud agent - Date ISSUED BY: � ORV
TOTAL:
OFFICE COPY