20995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pro ed Identification
Building Address: y '6 r7 PERhBT NO
�so4� T��rDE , c / 20995
nen true: one: - A
aZ o2S7—�7f CITY OF CUPERTINO-BUILDING
's 9d
C rectors Name: Lt..No:
o E paoiA2 n9 APPLICATION I PERMIT 9'
Architect/Engineer: Lie No: BUILDINGELECTRICAI:PLUMBING-MECHAMCAL CATEGORY CON7ROLp
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ifiereby affirm that lam Bcmsed underprovlelon,of Ch
APPLIANCESRESIDENTIAL ]OB DESCRIPCION
Ing with Sedlon 7000)of Division 3 of the Busl neer and Pro(edona Code,an d my
lireneJei�Is In(u (t d effect. e PANELS C
Dah`[�Contrector pnstt/ LMT0200ANTS
ARCHITECPS DECLARATION 201-1000AMI'S
pO. Iunderstandm lana shall be used as blic records OVER 1000 AMP$ S/SQ FI.
Y P W SQ.FT.FLOOR AREA
a
Licensed Pmfesslanal SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCTRCUIT/MISC
70 7� owingratRrmthatlam exempt Business
d Professions
Limns,Lw forth,
ii FZ following reason.(Section 7031.5,Bushes,and Pimp w Code:Any city.,1, TEMP.METER OR POLE INST.
s' ctuntywhlch requUeapermlt to comtrud,alter,lmprove,tlemollah,orrepalr
..: anystmdareprlmwibi ance,al...Vmstheapphcantfw,uchpermltto
file a signed statement that he I.limen pursuant to the provisims of the POWER DEVICES
di
Contractor'sLicense Lvw(Chapter 9(rommencing with Section 7000)of Div,- SWIMMING POOL ELECTRIC
� slon3ofthe Bualneeaand Profesloru CodOmthm heis exempt therefromand
kS S. m VALUATION
y.' the bean for the alleged exemption. Any violation of Section 7031.5 by any I ^ a OO
applicant subjects the applicant ttadvll pemltyana morethan - OVTLETSSWITCHFSFIXTUR�S A)
five hens owner of the pro NEW RESIDENTIAL EL 7R
�n ❑I,as owner of the property,or my employee with wages as their sale FT. SIURIEW PE CONSTRUCTION'
compansatlogwBldotheworkandthestmu mlanotintendedorofferedfor
D sale(Sec.7044,Business and Profeedons Code:The Contractors License law
does not apply to an owner of property who Wilds or improves thereon,and -
who doessuchwork himself wthroughhisownemployees,provided that such OCC.GROUIs RES.IINIT5
improvements arena Intended oroffered fwsale.K howevegthebu,lding or TOTAL
:mImprovement ssoldwithnomyearofcompleOoMtheowner-buBderwiilhave
hc burden of proving that he did not build or improve fm purpose ofsale.). FEE FLOODZANE AP
L f L as owner of the property,am excluslvely contracting with licensed PQtMIi L4SLU H T
contractors to construct the pas ed(Sec 70K Boameu and PmfmWm Code:
The Contractor's License Law does not apply to an owner of property who .DRAM k TER
Wilds or Improves thereon,and who contrails for ouch p7jed,with eAL
co�19fadore)licensed pursuant to the Contralto's Lice as
Law. BAIX WPR EVIC FEE SUMMARY
U I am OuTsinrEFES
exempt under B c. B h P C for thisreason
Ownerto i DRAINS K ,A ND. SANITARY Y N_
M
WORKAN COMPENSATION DECLAR TIO—� Z N���— RECEFrp, I hereby affirm that I have a certificate of consent to self-Insure,or a FIX SCHOOL TAX Y N
certificate a Workers'Compernation Insaranm m.cartiffed copythereof(Sec. RECEIPT If
Pow,Lpab C.)W^A_ I07 p�3 GAS EA. lIM�.4 EL PARK FEE Y_ N—.
RECCom any,1Q VT GAS EA.SY -OV 4 ) BUILDINGDIVISIONFEES
�CertBiedcopy la hereby(urnlahed. '
1.71
CERTIFICATE
TE wFEXE city ION FROM
GREASE/NDUSTRLWASIEI TOR PLANCHECK FEE
YW CERTIFTG MPE COMPENSATION
N FROM WOAKERs' GAFISE TRAP PAID
COMPENSATION INSURANCE
Rhbaection need not Wcompletel tithe perMt laforomhundred dollars SEWER-SANITARY-MRM EA. Date Recel t#
($100)or less.) ENERGY FEE
I o rtilythat In the performanceof the work fmwhich this permit is issued, WATER HEATER W/VENT/ELECTR Y N_
I shall not employ any person it,any runner an as to become subject to the WATl12 SYSTEM/TREATING PAID
Workers Compematbn Lawa otCail(ornla, Date
O Z Applicant - - .
Z ONOTICE TO APPLICANT;IL after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB.___SQ.7. be Revel t#
(/3
should become subject to the Workers'Compemna ation provbbof the Labor - TOTAL:
Code,you moat forthwith comply with each provisions or this permit shall be
LU > deemed revoked. BUILDING
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaRtrm that there la a construction lending agency for the perform-
M Z arm of the work forwhich this permit la issued(Sec.3097,Clv.C.) TOTAL: ELECTRIC FEE
O
V 0 Lenders Name - PLUMBING FEE
ly F "
Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
ave readthisappllutionand statethatthe above Information
11 lacomed.I agreeto comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEESPAID:
} N relating tobuilding construction,and hereby.whortre repm-ebt(re.ofthis
F Z dtytoenterupon the above-annuloned property for Inspection purpose.. ALTER OR ADD TO MUCH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
a slicer llabilitiea,prdgmenb,costsand pensee which may In any wayaceme AIR HANDLING UNIT(FO 10,000 CFM) .SUBTOTAL:
a -t acid Cilymc as�,npe o(1 seting of this permit.
`IK1L�•�i1- 9 �.1 AIR HANDLING UNIT(OVER 10,ODO CFM) CONSTRUCTION TAX
sl nature of Appeunt/Contractor Data V EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hammicus HEATING UNIT(TO 100,000 BTU) Date Rl'.eei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Codeioon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
C1 Yes
Will theappilcentor Nre Wildingoocopant use equipment erdevices VFNDLAITON FAN(SINGLE RESID) IG$UAIk]CE DALE
which emit hawrdoua arcontandrants as defined by the Bay Area Air IIF�3' �7
Illy Management Dist 7 BOILER-COMP OHPOR 100,000 BTU)
Ye c7
shave read the haatmode,Se tions 2 runts under533 Chapter.1 of BORER-COMP(OVER 100,000 BTU) SEI] 6S
the California Health& f Code.Sections 25505.25533 and 25534.I SEF�• s
understandthatifthe Ilding does not currently have atenant,that it is my NEW RESIDENTIAL MECH. SQ.FF - - -
respo ibility to
notify tthee�occcccuupant the requirements which must be
met (.�{�� (9�ry,�
f111
wnry 7-;-d�'/d W!S TM^s HH�,F/}Lk:.
Owner orauthoriud'age Date
TOTAL: ISSUEDB
OFFICE COPY