20921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identlflcatlon y PERMIT NO.
Building Address: 20921
Z. q J CSA-
wners a - one: A A
pa l CL U CITY OF CUPERTINO-BUILDING DIVISION
c rain same: uXNn': APPLICATION i PERMIT
- CATEGORY COMxoL
Architect/Engineer: Llc.No: x
BU[LDING-ELECIRICALPL[JMBING-MECHAMCAL
-. t tial - 5'V .'9j'1114 i • x'
4'n;, ,ELECTRIC PERMIT k4i�`.t4 iet=;FEE t t xt" iiBU[GDING PERMIT'INFO - q;`,�•5'
Address: . ,'�j P ' .� QA1 PERMITISSUANCE I� ❑,. „
LICENSED CONTRACTOR'S DECLARATIO yy
I hereby affirm that l am licensed under provisions of Chapter 9(rommenc APPLIANCESRESIDENTIAL 3T- El JOB DESCRHMON
Ingwith&dion MW)ofMvision3ofthe Bustnemand PmfeaslonsCo ,andmy . i -
licenre Is in full f rce and effect. '1 PANELS
�y]'�'(J
Licen1e k.x ��/ P _v 1 x`„moi
Date ic.aontrr
RCHITECTS DECLARATION 201-1000 AMPS i II
pQ±aO z I understand my plans shall be used as public recards. OVRR 1000 AMPS. I \ \ ! SQ.Fr.FLOOR AREA $/SQ.FT.
E (/ Licensed Profesebwl ,r SIGNS ELECTRICAL\
Gm OWNER-BUILDER DECLARATION \ !.['�.. .6
In Ig SPECIAL CIRCUIT/MIST, it M 1_ "ib
f„ [hereby afRrmlhatlam exemp[fromthe Contractor's License Law for the }.
following reason.(Section 7031.5,Business and Professions Code;My city or . TEMP.METER Oa
P t” cmntywhichrNuimapermltwwmtrirct,alter,lmprove,demolish,orrepair RP-OOLE INST.
`'ft anystructureprlortoitalasuance,also requiresthe appRrantfor such permit to ' POWER DEVICES g q
4,a file.a signed statement that he is licensed pursuant to the provisions of the
^qg�O Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- u
q 9 o'I'n R SWIMMING POOL�PL'ECTRIC k pj {q., -
O sion3efthe Buslnessand Professions Code)orthat he Vexem thercfromand ` k - VALUATION
f. ¢ the Weis for the alleged exemption. Any violation of Section 7031.5 by any 017ff.ErS5Wl7CHFSFfKTVRPSr A 1:
applicantfora perteritsubjects the applicant too civil penalty ofnt more than
five hundred dollars($500). NEW DE(:J'HAL ELECTR �� -SQ1rP. �p STORIES TYPE CONSTRUCTION
Z ❑I,as owner of the property,or my employees with wages as their sale
C ¢ compensatloe'wlll do the work and the structure is nat intended or offered for I ' 9 V, "`
O
In(Sec.7094,Business and Professions Cade:The Contractor's License Law M t
$ does not apply to an owner of property who Wilds or improves thereon,and \\ OCC.GROUP RES.UNITS
who doessuchworkhimselfoithrough hlaownemployese,provided thatsuch O'er - v
improvements are not intended or offered for sale.](however,the building or TOTAL:
ireprovement is sold within one yearofcompltion,the owner-Wllderwiil have •r,. "' -
t1
tf .urdeno(pmving that Mdid not build or improve for purpose ofaaleJ. QrY; ',a,lr�,,PCUN[BING'FBRMITc`fh"tt'%'.`• I.FEE;i` FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contratorb License Law time not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) MSAi7TARY
'
builds or improves thereon,and who contracts for such ptujets with a
c,➢.t{ator(s)licensed pursuant to the Contractor's License Law. - ERYI am exempt under Sec. B&P C forthis reason BACK FLOWPROTECT.DEVICEOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. Y_ NOwner Date RECEIPT x
WORKMAN COMPENSATION DECLARATION pLXgUReS.PRR TRAP Y_ N_
❑Ihereby affirm that I have a certl(ka[e of conrent to self-insure„ar a RECEH'Trerti(IateofWorkere'CompenssHonlauranceoramrtifiedropythereof(Sec. GAS EA,SYSTEM-1 INCAOUTLETSY_ N_3500,Lab C.)Policy^• GAS EA.SYSTEM-OVER4(EA) RECEH'fxCayr DING DIVISION FEES
Certified copy V ereby furnishes. GREASE/WDUSTRL WASTE INTERCEPTOR FEE
�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200FT. Date ., Recei t#
(This section need nt be complied If the permit Isfor one hundred dollars
($100)or lose.) waren HEATER w/veNT/n.ECTR ENERGY FEE 'Y N
I retma
ify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner w as to became subject to the WATER SYSTEM/TREATING”
Wmkers'CnmpensaHon Laws o(Califomta.Date - i. PAID -
O Z' Applicant - NEW RESIDENTIAL PLMB. SQ}T. Date Receit#
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
,F should become subject to the Workers'Compensation provision either Labor TOTAL:
WfA Code,you must forthwith comply with such provieloa orthis permit shall be_ OO .
j doomed'revoked. BUILDING E 9
ll a' _ CONSTRUCHON LENDING AGENCY SEISMIC FEE a
I hereby affirm that there le a construction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this tiaiswed(Sec.3097,Civ.C.)... � TOTAL ;
00 Leader's Narre x��Q�_ -• ..- ,. PLUMBING FEE
1- Lender'sAdsress RTY: "MECNANICA4`PERMIT t `? �',FEE;I;
- '-• MECHANICAL FEE' 013
W
_ Icertlfythatl havemad this application and atatethatthe above information
correct.l agree to comply with all city and county ordinances and slate laws /
O, PERMITLSSUANCE [1,(X FEES PAID:
is
}'y '' relaHngtob.11dingeonstmctlon,and hereby authorise representatives ofthis
f. Z city to enterupon theaWvnmenuoned property for Inspection purposes. ALTERORADDTOMECH.'
_ Date Recei t#
(We)agree to save,indemnify and keep harmless the City of Cupertino : . P
V, against liabilities,judgments,mstsand expense which may In anywayacerue AIR HAM]LINC UMT(TO 10,000 CFM) SUBTOTAL:
against alCit rn%n/a�9�yyRrrencp (th l 1 lep L• �h - -
\ � HANDLING UNIT(OVER 10,000 CFM) a' CONSTRUCTION TAX
K•< (� CONSTRUCTION TAX PAID:
f�ignature of Applicant/Cony tar - O-' 'Date EXHAUS'C HOOD(W/DUCT[ a
HAZAR US MATERIALS DISCLOSURE '
-
Will the applicant orfuture building ocevpant store or handle hazardous HEATING UMT(T0100,000 BTU) - Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the '
!
lealth
yes Safety Cade,S dioon 25532(a)7 .;y- : ; HEATING UNIT(OVER 100,000 BTU) TOTAL: �a 0
Will the applicant or�fu'ture building occupant use equipment or devicesVEN'RLATION FAN(SINGLE MID) ISSUANCE DATE '
which emit hazardous air contaminants as deflnedby the Bay Area Air
•�
Quality Management D�Bt 1ct7" - . . t BOILER-COMP(31 POR100,000BTU)
PYes ��II�No
havereadthehazahloLsmaterialsmquimmntsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) 14 0
the California Health&Safety Code,Setiom 25505,25533 and 25534.I fi U(i
understand that ltthebuildlng does not currently have a tenangt tit is my NEW RESIDENTIAL MECH. SQ.Ff
responsibility to notify he campI C111 of
s tof the u1 is whi be rr�t . .
prior to Issuance ecu
., nem or authotzcd agent Date - ISSUED BY:
' TOTAL:
OFFICE COPY