20278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea identification PERMIT NO,
Building Address: 20278 roabv an�Fv D� . G
nere _ one: A
�QLE CITY OF CUPER71NO-BUILDING DIVISION T.�
Co/nAtractoYaName:
Lit.Ng
APPLICATION / PERMIT - –a—" 1 -9 -
'CU 'LEC- C 17�63 BUILDINGMFCTRICAL-PLUMBINGMECHAMCAL ' CATEGORY CONTROLX
Architect/Engineer. Lk.No:
TY L+•, +,•tELECTRIU PERMiT+ tt+` .i,AE$Itt ?'':`.`�'� BU,IC•„INGTERINIT INFO
^ Address '.! FEBMITISSUANCE ��s� ❑ ❑ ❑ ..
LICENSED CONTRACTOR'S DECLARATION '
I hereby afirrathat l am licensed under provisions of Chapser9(commete. APPLIANCESRESIDENTIAL ]Og DESCRBaTTON
ingwithSealon7000)of Dlvision3otthe Businessand Professions Code,and my - '
limnm le In full f rce and stied. - ' PANELS '
Limn � -io Lia.» - r'�5�E3 7 - 1� �•. a'1� _ w
Dale Contractor�U�Es�-7�,. d £L�[' V
ARCHITECTS DECLARATION 201-1000 -
'goZO Iunderstand my plan shag be used as public records.' OVER1000AM pS' SQ.FT.FLODRAREA s $/SQ.FF.
Licensed Professional - SIGNSELFC CALrJ
Q�u OWNER-BUILDER DECLARATION '
In d CIlZC
p., Thereby afBrtnthatlass exempt the Contraeror's License Law the �' SPECIAL / -
oo following reason.(Section 70315,Business and Professions Code:Any city or ”
2t.[�, .METER OR LE]NST
countycture requlresabseamoalsore uanser,impnrve,demogsh,ormpairmirto
IN
anystructure prior to statement
that a Is licensed
puri tart to the pro uch inions of t e PO DEV]
0 Cie a signed statement that he to Iimn.ed pursuant to the provisions of the
3 m Contraci.rb License Law(Chapter 9(cormrencing with Section 7000)of Divi- VALUATION
�0 sion3o(the Budince...d Frofesaloru Codlmthat he ta exemptthere(romanit S G LELE
the basis for the alleg d.exemption..Any violation ofSection 7031.5 by any OUTLEVW" el 3, It
applicant fora permit subjects the applicautto a civil penaltyof not morethan S
�j
live hundrownered oftheans pO. NEWR TR SQ}7, STORIES - TYPECONSTRUCTION
j n I,as owner o(lhe property,or my employees with wages ae their sole
pensalion,wllldothew.rk.ndthestm m isnothumdedor offered for ,
Osale(Sec.7044,Business and Professions Code:The Contract.?.Lldenae Law _
3� does not apply to an owner of property who,builds or improves thereon,and - OCC.GROUP RES,UNITS
EE who does suchwark himselforthrough his own employees,provided that such ,lO
impmvementsarenct intended proffered for sale.If,howeveythebuildlegor - TOTAL:
improvement issold withinoneyearofcompletlorytheowner-bugderwlll have +.,+ - +
t e rden of proving that he did not Wild or improve for purpose of.ale)
QT'Y' + iPCUMBING'PEI M1, .i .?`•'fiCE:4, .FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with..conned PERMIT ISSUANCE
contractor to construct the partner(Sec.7044,Business and Professlnns Code:
Tb,.C.ntraaen.License Law does"not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or•improvea thereon, and who contracts for such pipjects with a C. t
,Il[�actor(s)licensed pursuant to the Conrado?.Ltmnse Law.. 'EEBt,$UMMtCRY'
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOK ROOF,AREA,COND. SANITARY Y - N
Owner .Date - RECEIPT
WOR KMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-insure pIXTURES PER TRAP SCITOOL TAX Y_ N_or - L RECEIPT p
certificate ofWorkera'Compeneatlonlesumme or a cemfied copythemof(Sec. GAS EA.SYSTEM-]INC.40UILETS PARK FEE Y N'
'3500,Lab ) pp
Polity p�G 9J O6 S3 GAS EA.SYSTEM-OVER 4(EA) RECEIPT i
Com anv LI/' BUILDING DIVISION FEES
.. I&CertlBed copy is file d- tume.city GREASE/INDUSTRL WASTE INTERCEPTOR, PLANCHECK FEE .
�Certitled copy ta filed with the city Irupealon division.
CERTIFICATE OF MEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Dale -Recei t#
(Thissectlon need act O be completed Nthe permit is!.rare hundred dollars
($10()or less.) _
' wark WATER rIEnrFx w/vENT/EI•ECTR. ENERGY FEE Y . N
I cont employ
the performance in anyh oriner o as to b camhis permit
subj is awned,
it • I.hall not employ any person in any mama. ao u to become subject to the WATER SYSTEM/TREATING - -
Workcra'Compemation Laws o(Callfomia.Date - •• PAID
10 Z NOTApplICE :. NEW RESIDENTIAL PLMB. SQ.EL Date Recei t#
Z NOTICE TO APPLICANT: after making this Certl(l-to of Exemption,you
rW should become subject to the Workers'Compensation provisions of the Labor TOTAL:.
�. Casae,you mu at forthwith mmply with such pmeisl.ne,mthis pering,lull be BUILDING FE
W j deemed revoked.
U C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z ']hereby affirm that there is a construction leadingagenry for the perforn, .TOTAL: ELECTRIC FEE 'p
7 ance Leads,.Name PLUMBING
this pe"is issued(Sec.3097,Civ.CJ
t
''.LL O . Lender's Name PLUMBING FEE -
F Lenaeranaare.a QY „ t MECFIR "ICAC'TERMIT' t .:l``>CE•zii MECHANICAL FEE
O Imrtifythatlhavereadthsapplicatbnandsta
0 W hthatthe above in(ormatlon
1 Iscorrea.I agreeto comply with all city and county,ordinances and date law. PERMIT ISSUANCE FEES PAID:
} relating 10 building con.tmdim,ral hereby authorize representatives of this - _ -
city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.' Date ReCei t#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino ae P
-
ago bNtlea,judgmenta,coeteaed expe which yin mywayacems AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL'
abut Id City inconuque (lM gr' tl of this - ,
C.—/ AIR HANDLING UNIT(OVER 10,000Cr•M) CONSTRUCTION TAX -
mofApplicmt/C ado D e IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALSD CLOSURE -
brWilltheapplicantorfuhmbuBding.mpantstore or handle haurdous HEATING UNIT(TO 100,0D)BTU) Date Recei f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Q
Health and SCoafety d Sed? n 25532(.)7 HEATING UNIT(OVER 100,000 BTU)
❑ Yea 'IPO
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUA C,DA;gS
which emit havardous air contaminants as defined by the Bay Area Air -
Qu❑abty ManagementD�Wa7 BOILER-CAMP(3FN OR 100,000 BTU) r•f
IJQNo
ve read the hazGT��iii o--vs materials requirements under Chapter 6.95 of BOILER-COMP,(OVER 100,000 BTU) ra aap}�SU=•
the California Health&Safety Code,Sections 75505,75533 and 25534.]
understand that if the building does not currently have.meant,that it is my NEWRESIDENTIALMECH. SQ.FT.
Itytonolifytheoovpanfofthe hemenl which must be me
prior to Lss once ofa Certili at f ccu
60 S�I � S X� .
Ow or au hone agent Dace - ISSUED BY:
TOTAL:
OFFICE COPY