20990 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Addres.:
20990
G O n n
O
.e
ull,
CITY OF CUPERTINO-BUILDING DIVISION D
^� Lk Na APPLICATION I PERMIT r�
�LkK L-� BUILDINGELECTRICALPLI1MeINGMFLHAMCAL CATEGORY CONTROL
Architect/Englnee_ Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address.:
PERMITISSUANCE I'�(,x f� � � fill
LICENSED CONTRACTOR'S DECLARATION �J e��
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES.RESIDENTIAL IOB�ESCRITTION
Ing withSealon 7000)of Division 3 ofthe Buslnes.and Pro(esslonsCode,and my �AAB `
license la In(uR fpa�e and dtact. r/�(� PANES f�'7 ft _\Y14_..
Llccnse Class 1�_LIc.X L.R L L�S �`l `O t'_
Date Contractor 12 IQ 2QQAMPS ,
ARCHITECTS DECLARATION 201-1010 AMPS
pQ!Q X20 I understand my plans shage useas public blic records. OVER 10D0 AMPS SQ.FF.FLOOR AREA S/SQ.FC.
k (9 Licensed Professional SIG L firms 7 L
OWNER-BUILDER DECLARATION SppL T/ _ r / Y V
1hercby.ffl.that lam exempt fthe Contractor's License Law for the S—r �
❑❑ following reason.(Section 7031.5,Business and Professions Code:Any city or
mr
s" countywhich requiresa permit to construct,alter,Improve,deollsh,orrepalr TEMP. Q POLEINST.
an ystmmmprlortoit L anceatsomquimstheappbcantforsurhper tto / V
'rE Rle a signed statement that he V licensed pursuant to the proallam of the I'O ( SFr7.e�
O u,� Contractors License Law(Chapter 9(comnxrreng with Section 7000)of Diel- VAC SWIMMING POOL ELECTRIC Z, C/LUAAON
, 1
, slon3oftheguslnes.and Profemlov C°de)orthathelsexempHhemfmmand �eac� Ys-P C V
W5p' the basis for the alleged exemption. Any violation of Sectlon 70X.5 by any ct
applicant fora permit subjects the applicant to a civil penalty of net more than OUTLETSSWITCHESHXM4FS 0
a
five hundred dollars hepr. NEW RESIDENTIAL ELECTR SQ.Fr. 7yp. ICTION
X, ❑I,as owner o(lha Property,or my employees with wages r thele sole
t
compensation,Bu.istmd work Prandthes Code:
Th not Intended oictfes d for
Lave
$ O doe setappl,to
nee Professions Cob uild&Contractors throve Lave
does not apply to an owmrofproperty who builds orimprwesthercory and OCC.GROUP RFS UNITS
C• whodoeeeuch.,khl .elforth.ghhisownemployees,p.idedthat.0 h
imp.s.ments arena Intended oroftered forsale.If,however,thebullding or TOTA
Improvement Issold withinoneyearofcompldion,theowner-bullderwlll have
the burden of proving that he dal not build or Unprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
F]L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to conatmet the pmject(Sec.7064,Business and Professions Code:
The Contractor's License Law doe.not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) 2�
builds or Improves themone,and who contracts for such plojeM with a TFEE SUMMARY
f+&eels)licensed pursuant to the Contractors Limnse Law. BACK FLOWI'ROTFLT.DEVICE
�I am exempt under Sec. B k P C for this maven
OUTSIDE I'l CS
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
RECEIPT
WORKMAN COMPENSATION DECLARATION FDnURES-PER TRAP SCIi00L TAK Y N
❑I hereby affirm that I have a certificate of consent to mtNrisurc,or• I-I.v.' RECEIIrf X
3800otnitrlate C.Warker Camper at nlwurance oracertl(kd ropythemof(Sec. GAS EA.SYSTEM.1 INCA OUTLETS eZ,CX) PARK FFR Y N
Policy a—_-* � DINGRECEIPT p
Co�^ '� Y V GAS EA.SYSIAt-0VERI(EA) BUILDINGDIV]SION FEES
Mill V em tum a city GREASE/INDUSTRL WASTE INTERCET'TOft PLANCHECK FEE
rtified copyaflled with the city inspection division.
p r- X7.1
CERTIFICATES I N FROM WORKERS' ]GREASETRAP PAID L� �
COMPENSATIONINSURANCE SEWEWSAMTARYSTORM EA 200Ff Date Racei tIf
(TM1bsealon need not be completed[(the permit le(.zone hundred dollars
(StOo)orlea.) WATER HFATMW/VENT/ELECTR ENERGYFEE Y N I1 D
[certify that In any person in nymanner n as to become
eesubjecrmit I.issued, �V
I Work not empty any person In any manner at as to become subJtt[to the
Workers'Compensation laws of California. Date WATER SYSTEM/TREATING PAID (., <<
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recel t
Z O NOTICEco esubjM APPLICANT. rs'Comakinlerhis Ctionpreo(ons of
the Labor
should become sub hMt the Workersh.a hpnsatlon .,thiop of[.Labor TOT
V2 doomed
thwithcomply withauchproWlov orthb pemdt shallbe [ELEC`qHCM)E
S •x00
W > deemed revoked.
CL C CONSTRUCTION LENDING AGENCY EE
I hereby affirm that there V a construction lending agency for the periortry
Z anceoftheworkforwhichthhpmMtb Weed(Sec.3097,Civ,C.I TOTAL:
(.) 0 Lender's Name M INGFE.
IL I— LendersAddress QTY. MECHANICAL PERMIT FEE HAN E
OW I certifythat I have mad this apphotionand Gatethauheabovelnformationt''')1Incorrect.Iagree toromplywlth all city and county ordinances and pate UwsPERMITISSUANCE I40, P
} mlatingtobuilding construction,and herebyauthorize representatives ofthbzcity to enter upon the abov nrxxrtloned property for inspection purpose. ALTERORADDTOMECH. lZ (We)a;1'CApplus,
e to n,Indemnl ep harmless the City of Cupertino vale ece1Pt(F
against lbt dgmenb, s xpeass.which may In my way accrue AIR HANDLING UNIT(TO t0,OD0 CFM), SU OTAL'
against sol ' ronaryu ce granting of this permit.
/ r AIRHANDUNG UNIT(OVER IB,DDOCFM) CONSTRUCTIONT
5lgemu re /Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE }�
Will the applicant or future building occupant store or handle hazaT
rdous l HEATING UNIT 100,000 BTU) sd� Date
Yes . I]Na Rece Ile
material as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the -
I lealth and Safety Cade Section 25532(a)7 ['(EATING UNIT[OVER 1 W,IRp BTU) L:TOTA
❑
Will the applies est orfutu re building occupant use equipment or device VFMT LATION rAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous acontamlm nrs as defined by the Bay Arca Air PAI
Quality Management DisWat BOILER-COMP OI-B'OR 100,000 BTU)
4 Ye> No
have read the hav esus twlcrlals requlrcrrenb under CFapler 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Glifomla Health k Safety Cotle,Sealm ently have a tenant,
that it MAS{ �. 61981
understand that if the building does
not ectimeentlyh,25533ard255M ltbmy NEW RESIDENTIAL MEC[{. SQ.Ff.
responsibility to notify the occupant of the requirements which must be and
prior to Issuance of a Certificate of Gone pa nry, est,Of CUL" rfm
Owner or authorized agent Date ISSUEDBY city J
7OTA L: y V
OFFICE COPY