20673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEtMITNO.
BuildingAddress; 20673
I D x L'I C W VLAcF.
note ams: one: _ A
- - CITY OF CUPERTINO-BUILDING DIVISION
ontraer, N'IN9�0 Llc.Nn: APPLICATION I PERMIT
ArchBUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL a 'stQ
Lk Nm (/ [
C 29OS QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:'! W�s�T\s ` ( PERMIT ISSUANCE 'Q' +�
LICFNSEDC NTRACfOR'S DECLARATION � APPLIANCESRESIDEMIAL Ley �I
thereby affirm that lamllcensed underprovblonsof Chapter9(commenc �t ]OB DFSCRTHDN
tngwlthSection 7000)ofDivl4an3oftheBukmmand ProfeulonsCode,and my /•--1�� L�
license is In fulll effect. �s PANELS
License —Lic.
r—Contract
e. 271 . �S Yt
Date e Q/
ARCHITECI'SD CURATION XII-IOOOAMPS
PQ!m z nd my plarishall u b cx rds, OVER I OOO AMPS SQ.Fr.FL R ARE yS/SQ.Fr.
E LI mfess u SIGNSELECTRICAL 7S(� / 9 L
«<< OWNER-BUIL ER DECLARATIONS
O fn PECIAL CIRCIRT/MISC
1"' !hereby a(Oem that lam exemp fromthe Contractors Lkenr law froths !1/�_
2. 33 folbwing rea+on.(Scction 7mt5,Busine®and Pmfealons Code:Mytltyor ,.v� �/c/. Q
K"�sy wuntywhkh requires a permit tomrutmct,alter,Improve,deemllsh,orrepalr TEMP.METER OR POLE!NST. Ot CXJ
q�
3 anystme mpdortolb Wuame,alsorequtreatheappllantforsuchper tto POWER DEVICES �i1-
45
file a accord statement that he b r 9(commencing
pursuant it the provisions of the
Q6
Contractor's usineetaw(Cha io9(mmmendn with Section and VALUATION
3 u'r'n � B SWIMMING POOL ELECTRIC
sloSOS the basis fo the
Pmfembn. Any violation
of exempt therefrom and
G the bash for the alleged exemption.an. Any vlolacivi of penalty
on not room
by than
OUTLEISSWITCHESFIXITIRES s oD
appBantfor a Esimil subjects the appOnnt toadvll penalty of not rtnrethan O Z
five hundred dollars(SM. NEWRFSIDDMALFLECTR SQ,FT. STOW TYPECONSTRUCTION
�n ❑I,as owner of the property,or my employees with wagesas theirsole
mmpeoaatlon,wlll clothe wont,andthe gmclure Isnot Intended or offered for
it O sale(Sec 7044,Boohoo and Professions Cade:The Cantnctors License Gov
$$ does nor apply to an owner of property who Wilds or Improves thereon,andRFS.UNITS
who does such work himself orthrough his own employees,provided that such
ImprovementaamnoH tendedorofferedf¢ule.If,hmvever,thebuildingor T 41 {L�-
improvement bwld withinoneyearofcompletlogtheawner-bullderwill have
t1yrJ,urden of proving that he did rwt bund or Improve for purpose of sale.). QTY. PLUMBINGPERMIT
LJ APN
L as mucor tr the Property,am.70K usi contracting with licensed PERMITISSUANCE
The Co nn to mriswd the project(Sec.7014,Bugness and Professions pro oro Code:
The Contactors License Lw does nor apply to an owner of property who Cr
Wilds t r improves thereon,and who mnemes for such pt,oj+cts with a ALTER-DRAIN&VENT WATER(EA) - 'Zs FEE SUMMARY
Cgll[�admexe licensed exempt
Sec.nt the Contractor's Lk en ae Lew. BACK FLOW PROTECT.DEVICE
I LJ I am exempt under See. B k P C for this reawn
OUTS I UP FEES
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N_
Owner Dale BE=a
W00.KMAN I have.95ATION DECLARATION FI%.R7RFS7'ER.IRAP LQ� SCHOOL TAX Y N_
❑i hereby oricern that I have•certNate of consent to copy
ora L AFCFR'f a
certlBmoo/Workers'Compensatlanlnsuan¢ma¢rtifled ropy thereo((Sm. I GAS E.SYSTEM-I INCAOUILETS 2C25 PARK FEE Y N_
Policy
# CJ RECIBPTa
Polity R GAS E.SYSTEM-OVER 4(E)
Com any BUILDING DI VISIONITES
Certified copy Is hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE D
❑CertBledropyIsflledwiththedtylmpectlondivislan. 3s
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XIOFf Date Recei 1p
(This auction need cat be completed If the permit Is intone hundred dollen
($100)mless.) 00 ENERGYFEE Y N ` q
I certifyWATER HEATER W/VENT/ELECTR that in the performance ofthe work forwhich this permit la Issued, (IdaD?
' I slualt not employ any person In any manner an u b me a to tot
WATER SYSTEM/TREATING
Worke.'C cation LawrofO a.CDate PAID
Z
Applicant NEW RESIDENTIAL PLMB. SQFT. Date Reuel Hf
Z O NOTICE'M APPLICANT:R,aft rmak Certificate of Exemption,you
Hshould Wcumesubjottothe Works mpemation previsions of the Labor TOTAL: a
fA Code,you must forthwith comply with such provisions or this permit shatl be TNG
deemed revoked. BUILD '-T
FEE
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE -CLQ
IL Z Ihereby affirm that there is a construction lending agency for the perforem - TOTAL: ( ELECTRIC FEE
D a n..ftheworkf.�rwhi thltgypermit is heated(Sec.3097,Civ.C.)
60
Lenders Name —R /6yL- PLUMBING FEE C►-7
LL H lender'sAdd Q /r' QTY. MECHANICAL PERMIT FEE MECHANICAL FEE caO W IcenifythattluvemadthtsappOoBonsMdatelhattheabovelnformation
IL Is correct.I agree to comply with all city and county ordinances and gate laws PERMITI.SSUANCE �� FEES PAID:
W relating to building construction,and hereby authogss representsttvesof this
F cityto enter upon the abovcmentioned property for Inspection purposes. ALTERORADDTOMECH.
Z Date Recei tk
V — (We)agree to save,indemnify the City AIR HANDLING UNIT P
against llabllillue,jrdgmenta,cogaand ezpunaea Mthi.mryln anyway accrue (TO)0.000 CPM) SUBTOTAL:
r' ainst.Id Clty i.c.n xryenceofthegrantingafthle peemit AIRHANDLING UNIT(OVER 10'llooc M) CONSTRUCTION TAX
-SIgnaEreeof Appfice onlndor Date EXHAUST HOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDO ERIALS DISCLOSURE
Will theappliant or building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) '�,t9a Date Recel tN
material as defied by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 75537(.)7 HEATING UNIT(OVER 100,OW BTU) TOTAL: 7..0
❑Yea No
Wllltheapplla et or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazaedous air mntaMmnts as deflned by the Bay Area Air
W lily Mawgemcrn Dindd7 BOILER-COMPOHPOR 100,000 BTU) R"f
4YesNo
haveread the h.2usmaterials requirements underChapterG95of BOILER-COMP(OVER 100,WO BTU) I.�C[�j
the Callfomla Health k Safety Code,Sect Ions 7.SSO5,75533 and 75534.1 x) f (,a 1 S90
undemta rd that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.Ff
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. ofrlinP
City ,
aA /. !. ItIPD
� 3 ..
Owner or aulhodud agent Date TOTAL: �ty ISSUED BY:
�!
OFFICE COPY