20803 APPLICANT TO FILL IN INFORMATIONVITHIN RED,LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 'wk,� 20803
S Stn L
ours one: A AIL
CITY OF CUPERTINO-BUILDING DIVISION
Ceno-ad name: {1 1,75 110
APPLICATION I PERMIT,-1
ERMIT, Cl
SOSS11O BUILDING-¢ECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL N
r,
Architect/Enginee , -Lie.No ,
�•c// aN13 pp • ''= .t'`� BUILRINgPERMITINFO
Addicae:15756 Ii5 0. /—N - PERMITISSUANCE '
LICENSED CONTRACTOR'S DECLARATION � 1:1 0
I hereby affirm that l am licensed under provisions of Chapter 9(commeno- APPLIANC ENTIAL JOB DCSCR{{{��pggq''''ON
ingwith Sedion7(00)of Divisian3ofthe Busineasand PmfessionsCode,and my
license le In(u duffed. PA
License Clam
Data Coot 5r 0�.
ARCHITECTS DECLARATION a 21-1000 rt.V
skk b VV
OVERT SQ.FT.FLODRAREA $/SQ.Fr.
q�+0 CZO. I understand my plan shall be used as public records. .
L�(0 Licensed Professional SIGNS EL CAL '
6�3 OWNER-BUILDER DECLARATION TECIAL CULT LSC "
7L � Iherebyafflrm that am exempt fromthe Contractors License Law for the
op following reason.(Section 7031.5,Business and Prafesslons Code:Any city or
GZt' =ntywhichrequlresapert ttommtmdalteplmpmvedemolish,ormpalr P. O L B
any structure pdorm lis issuance,akorequireatheapplkant forsuch permitto
file a signed statement that he Is licensed pursuant to the provisions of the ` DEVICE ,
Contractor's License law(CFa er 9(mmmencln wltM1 Section 7000 0(Dlvl-
�0 sion3ofthe Businessand ProfembruCode)orthagheisemmptthemfromand Swart GIOOL RIC VALUATION
y� the bask for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS TCHES-FIXTURES
05 applicant for a permit subjects the applicant to a civil penalty elect more than
five hundred dollars($500). ,
�n ❑I,as owner of the ro NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
p party,or my employees with wages r their sole
C compensation,weldess and work,Pr andthe s Cdureknot
ontractor o icensoffered Law
5J O doe(nec.tappy to an ower Professions who
Wilds or Improves
License law
rjS does not apply roan owner ofproperty who buildsorimprovesthereoryand OCC.GROUP RES.UNITS
AA
who does
m,nisa notintelf or dedorwgred far own employees,If,ho a,er,theprovided ildingsuch
Improvemxnleare not intended or offered far sale.If,however,the building or TOTAL: - •
improvement ksold within one yearof completion,the owner-bullderwiil have
itLe�trden of proving that he did not build or improve for purpose of sale.). QTy;`: PT:UI�QIIINGPERM/T ?`. FES,' :` F DA ZONE APN
u I,as mailer of the property,am exclusively contracting with licensed PERMIT ISSUANCE � � D/0
contradms to construct the project(Sec.765y Business and Professions Cade: - V
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
WEds,or fniproves thereon, and who mntrada far such pipjects -with a ;,-.FEE'S,UMMARY',
c,,l!LLtrrador(s)licensed pursuant to the Contractors License Law., BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B&P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y . N QQT�Irm FEES
Owner Date RECEIPTa
WORKMAN COMPENSATION DECLARATION FLXTURF_e,PER TRAP _oP SCHOOLTAX Y N
❑I hereby affirm that I have a cerearso of convert to copy
ora RECD,p
certificate o(Workeme'Compersatlonlwurance oracerti(led copy thereof(Sec. GAS F.A.SYSTEM-[INC40UTLErS PARK FEE Y . N
Put Lab CJ
` PolicyN GAS EA.SYSTEM-OVER4(EA) RFLEB'CN
Com
any
)NSYLpAC� BUILDING DIVISION FEES
�Certifled copykhereby famished. GREASE/INDUSTRL WASTE INTERCEPTORPLANCHECIC FEE
❑Certified copy k filed with the cityinspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID, `
COMPENSATION INSURANCESE'WF.A-SANHARY STORM EA.200FT. Date Recei t#
(This section need not be completed if the permit k for one hundred dollars
($100)or less.), WATER];TATER W/VENT/¢GCTR ENERGY FEE Y N
I certify that In the Punic ..&the week forwhich this permit is issued,
I shall not eTRplOF anyApereon In any manner so as luyegpm.a�ey�t lathe WATER SYSTEM/TREATING
We"..
C/Sfiy9q(,a((6(`i=of California.Date,__/-��-•tea_ 13 PAID '
O Z Applicant— NEWRESIDENHALFLnte. sQ.Fr. Date Recei t#
Z O NOTICE4b APPLICANT.If,after making this Certificate of Exemption,you
Fshould become subject to the Workers'Compersatlon provisions of the Labor - TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be BU N FEE
W ] deemed revoked.
11CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afOrmthat there is a construction lending agency forthe pertrm- a� ELECTRIC FEE
M Z ance of the work for which this permit is fssued(Sec.3097,Civ.C.) TOTAL f4rU
•V O Lenders Name - < PLUMBING FEE
IL H Lenders Address QTY;'ii , MECHANICAL"PEBINIT FE&:;' MECHANICAL FEE
OWIcertlfythatINvemadthkapplimtionandstatethattheaboveinformatlan
a kmrrect.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} relating to building corotmdion,and herebyauthmlze representativesofthis -
(— Z + city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
agalma Ilabilllles,jadgn k,c tsand expenses which may in anywayaccrue - AIR HANDLING UNIT(TO 10,0W CFM) SUBTOTAL:
airy iI)9u c of the granting of this permit. - -
�, ® •�J �� t/'1� AIR HANDLING UNIT(OVER 10,o0o CFM) CONSTRUCTION TAX
g ature of Applicant/Contractor /_ . Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the appliesnt or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date ` R0ef1 [#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Ilealthand Safety Cade�+.-S�ection 25532(a)? HEATING UNIT(OVER 100,000 BTU) OTAL:
F-1YesI__I No -
Willtheapplicunt orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I $ 'E DATE
which emit hazardous air contaminants as defined by the Bay Area Air 5 ,l
Qua lity Management District? _ '+ BOILER-COMP 0HP OR 100,000 BTU) I �U
Yes I�I No '
ave read the Nazar ous materials requirements under Chapter 6.95 of BOILER-OOMP(OVER 100,000 BTU)
the California Health&Safety Code,Serthma 75505,8533 and 25534.1 .y
no land that iftheb ding ousnot currently have atenant,that Itismy. NEWRFSIDENHALMECH. SQ.FP. C' gf,l,CuuerUoo `
po siblI", to oli eoc pant of the requirements which mu at be met `
psi to Lssuan Aft teof0ccopancy. - '
r LS 9G
neror JUthonaV agent, .. Data ( TOTALISSUED
BY:
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OFFICE COPY