20737 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Printed Identification
PERMIT NO.
Building Address:
(J/,(i/ //✓� T G`. T rnl e
20737
ane:
AppucATM79119AL DATE
N�
LUL,fIL
Contractor's Name: LIc. No:
CITY OF CUPERTTN0.6UILDINC DIVISION
APPLICATION / PERMIT
—1 — 1 0
BUILDING-ELECTRICA PLUMBING-MECHAMCAL
CATEGORY
CONTROL p'' R
l9
A to neer 'C ` Lic. No:
7
QTr ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: C Lr
PERMITISSUANCE
❑ ❑ ❑
LICENSED ONTRACTOR'S DECLARATION
I hereby affbm that l am licensed under provisions ofChapter9( c
Inensc isenion7000)ofdeffiron3ofthe BuslnnsandProfesslonsCode,an my
lirena Is in fu8 Torre and dfen.
APPI]ANCESRESIDENTIAL
PANELS
JOB DESCRB'DON
License Class LieN
Date Contractor
UP TO 2DO ANTS
201-]000 AMPS
ARCHITECTS DECLARATION
]understand my plans shall be used upublic ramrds.
OVER1000AMPS
FLOOR AREA
Licensed Professional
\__.FT.
SIGNS ELECTRICAL
e 1Ct Boo
�75/SQaFI.
/4Lq)_
OWNER -BUILDER DECLARATION
Thereby affirm thatI amexempt from the Contractors License Lawforthe
�j1i
LLYY -
ZSI0O
SPECIAL CIRCUIT/MLSC
7EMp METER OR POLE INST.
followingreasun.(Section70315, Bmud.,ind Profeaioro Code: Any dtyor
county which requiresa permitromoamict alter, improve, demolish, orrepalr
'
any structure prior to its Issuance, also requires the applicant for such permit to
Ole a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divl-
slon 3 of the Business and Profession m
Cocie) crib. he b exempt therefrom and
the WSIs for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora pemdt subjectethe apphcant to a dvil pemltyofnot more than
DEVICES
MING POOL ELECTRIC
SVk4VALUATION
O 'ISSWITCHESFIXTURES
��..aafX1A
NEW DENTAL ELFG7R hT'
five hundred dollars($SM.
❑ I, as owner of the property, or my employees with wages as th Ir soie
STORIES
TYPE CONSTRUCTION
compensation, wRldothe work and thestrunure Is not Intended or off for
sale (Sec.7044, Business and Prefemlom Code: The Coruncer's Licem Law
AL:
QTy. P B GP MIT "E'
PERMIT UA
AL -D VENT- ATER (G)
does not apply to an owner d property who Wilds or Improves there, and
whodoessuch work himetIforthrough his own employees, provided tha such
Improvementsarenotlntendedorofferedforsale. If,however,thebuildi gor
improvement usold within oneyearo(Completion, theowner-builderwill ave
tndenofprovingthathedid ndbuildorimproveforpurposeofu .).
I,uJ { as owner of the property, am exclusively contracting with Iia sed
contradorsto construct the pmjed(Sec. 7044, Business and ProfeaslonsC e:
The Contractors License law does not apply to set owner d property ho
Wilds or Improves thereon, and who contracts for such pipOcts wit a
cQtLtradoda) licensed pursuant to the Contractors License Law.
I_J I am exempt under Sec. B & P C for this reas n
C IIP
RES. UNITS
FLOODZOhr
APN
B WI'RO T. ICE
FEE SUMMARY
OUTSIDE
Owner Date
S FLOOR R F AREA,
TIJAES PER
SANITARY Y N
RECEIPT X '
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a rerti0ate of Consent to veli -Insure, or
renifiate o(Workeme'Comperwtion Imuurana ora rerti(kd ropythereof (Sec
3800, Lab CJ
Policy N
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. SYSTEM -1 IN .d OUTLETS
PARK FEE Y N '
RECEO'T X
Com any
- ❑pCerlNed copy Is hereby furnished.
❑ Certified copy Is filed with the city inspection division.
CERTIHGTE OF IO(EMPTION FROM WORKERS'
GAS -OVER (EA)
GREASE/INDUSTRL WA INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE Ny
�Ot�
GREASE TRAP
COMPENSATION INSURANCE
(ThIssedlon need nd a completed if the permit Is f°rone hu reddollam
($100) or less.)
Iartlfythat Isthe pedomunre of the work lorwN<h lM mtlt is issaed,
I shall not employ any person in any manner so m to be me subject to the
Workers'Compensation laws of California. Date
Ca
Applicant
Applicant
PAID
Date Recel t#
SEWER -SANITARY -STORM 200FT
WATER HEATER W/VENT/ TR
ENERGYFEE Y N —
1'� pis
PAID 4� —W SG743
Dale Recel ted
�qrs
0,vv
WATER SYSTEM/TREATING
hO77CE TO APPLICANT:IL after making lhIs Cert ate o(Exemptmn, you
should become subject to the n provisions of the Labor
Code, you must forthwith comply with au ch pro IonsorthispertNtshallbe
dee
deemed revoked.
hrELV RESIDENTIAL PLMB. SQd.T.
TOTAL:
a
BUILDING '
CONSTRUCTION LEN 'C AGENCY
[hercbya(Ormthat there Isacorotm n lend Ingagency for the pedormn
ce of the work for which this permit ed(Sec. 3097, Civ. C.)
larder's Nacre
I omifythat thIsap anonandstatethattheaboveinformatlon
Lenders Addre7thal�
bcorremlagrlywit B city and county ordinances and slate laws
relating to builmed , and herabyauthorlumprexntativesofthIscity to enter upvo ntiorudpmpertyforWpectloopurposea.
(We) agree d mnity and keep harmiess the City of Cupertino
agaWtilabilltieb,cats,.ndexpenwswhlchmayinanywayaccrue
agaustsaldClen« ofthe granting ofthis permit.
TOTAL:
SEISMIC FEE
ELECTRIC FEE
,
QTY- MECHANICAL PER T FEE
PLUMBING FEE
PERMIT ISSUANCE
ALTER ORADDTO MECH.
AIRHANDLING UNIT(to I%=CFM)
MECHANICAL FEE
FEES PAID:
Date Reeeiptri
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000CEM)
CONSTRUCTION TAX
Signature of Applinm Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
MATING UNIT (TO 100,00 BTU)
Will the applicant or future building occupant store or hand le hazardous
material as defined by the Cupertino Munidpa l Code, Chapter 9.1 2, and the
Health and Safety Code Section 25532(x)7
F-1Yea' N No
Date ReCCI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL"
Will the applies nt or future bu ilding occupant use equipment or devices
which emit havardous air cents minants as de fined by the Bay Area Air
Quality Ma mugemcnt District?
Yea ❑❑ No
have read the bar allouamvuriab requirements under Chapter 6.95 of
the Ceiifcmia Health & Safety Code, Sections 25505, 25533 and 25534. I
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
BOILER -COMP OTE' OR 100,IX0 BTI)
BOILER -COMP (OVER 100,000 BTU)
understand that if the building does not currently have a tenant, that it u my
raponsibllity to Airy the occupant of the requlrenpnts which must be met
priortol uanceofa Certificateof Occupancy.
NEWRESIDENTIALMECH. SQ.FT
'
ISSUED BY:
Owner Cr authodaed agent Date
TOTAL:
OFFICE COPY