20953 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildins Pm'e[t Identification PERMITNO.
Building Address: 2 0^5 3
jaal $�Kwe(I Dr G .yf �(J
-At. .me: One:
r carnes, - 15A-6154� CITY OF CUPERTINO-BUILDING DIVISION A
Quo!aNi11G1 r`G -No: APPLICATION / PERMIT 30-
rchitect/Engineer. Ltc No: BUfLDINGELECTRICAI_PLUMBINC-MECHANICAL CATEGORY CONTROL N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add..
PERMITISSUANCE ❑ - ❑ ❑
Lom that ED CONTRACTOR'S DEC ns of ChON
Ihereby
ection70 that amlkmsedunder Business
Pro ChionfiC(mmmm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
' Ingwlth5ect1on7000)of Division 3o•(�thegusineaeand ProleaslonaCode,and my
Ilcense leis lnl� mucotiTcamileffect. O PANELS
Lice LbN Ot III!TO 2DO AMPS
Date Contractor
ARCHITmECLARATION OVER00 AMPS
�❑+rezOO ]a[�ar tr►'pla B a/s public records. OVER 10110 AMI'g �.Ff.FLOOR AREA 5/SQ.FT.
LicensedProfessionalT�' SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C
a., 3 Ihereby affirmthatIamexempt from the Cmoretm'e License Law for the
following maaon.(Section 70115,Business and Prefessiona Code:Any city or - TEMP.MEFEd ORPOLRINSf.
p4 countywhlch requlresa permRtoconstrect,alter,Improve,dennlhh,orcepair - .
.anystructure prior to ltshsuance,aho mNimatheapplIantf.rsuchpermitto pOWgg DEVICES
C file a signed statement that he isBcensed pursuant to the preWioro of the
3µI= Contnct.es License Law fChapter9(mmmenWg with Section 7000).(Devi. SWIMMING POOL ELECTRIC
El
elon3of the Business end Pre(essbroCode)orthet he kezempttherefremand VALUATION
the bash for the alleged exemption. Any violation of Section 7071.5 by any
«
applicant for permit sub thea Meant to a civil 1 of net more than OUTLETSS'WHCHE&FlXIURFS
p fve Pe )'eta PP Proty 00C Clt�
$
five hundred a sr owner of thep00. NEW RESIDENDALE TR SQ. , STORIES =CONSTRUCTION
�n ❑Las owner of the property,or my employees with ween ea thele sok
compensation,7K will do the Business
and the sull. odurehn Intendedontractor or offeredLaw
ale LSen 7091,Business and Professions Code:The Gontnctol's License law IN
don not apply to an owner of property who builds or improves thermn,and OCC,CROUP RES.UNITS
whodoeeauchwmichinvelforthrough hisawnemployees,provided that such
Improvements are not intended or.fferedfersale.If,however,thebuilding or - TOTAL:
improvement hsob within one yeamfcompletti.n,the owner-builderwill have
t B urden.!proving that he did not build or improve for purpose of sale.). Q P IN IT FEE FAD ZONE APN
Luf L as owner of the property,am exclusively contracting with licensed N
contractors to mratruct the project(Sec.7094,Buslness and Professloro Code: '
The Commerce.License Law does not apply to an owner d property o TER D •WATER
or improves thereon,and who contracts for such p(ojects with
c act.r(e)Il...d pursuant in the Comrade's License Gov. BACK pTAW PROT T.DEVICE FEE SUMMARY
LJ I am exempt under Sea B k P C for this mason
DRAINS R F,A CO SANITARY Y_ N
Owner Data RECEIPT 0
WORKMAN COMPENSATION DECLARATION TGREASr
- SCIR)OLTAK Y_ N
�I Femby d(Irm that I have a mrtlRute of consent to self-ima re,ora RECEIPT N
iffa a of Worken'Comp uaat((lan l 6t ca ma certified copythertof(Sec.
Poli Nb C.) 1Q��OOf� � IL PARKFEE RECEIPIN
Co�rrrrp ifi.S t t ) BUILDING DIVISION FEES
I]QC[rtlfied ropyhhereby famished. NTITRCEIPTOR PLANCHECK FEE
1 niBed copy h filed with the city inspection division.
CERTIFICATE OF E)tEMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA pOFF Date Reaal t#
(Thissection need not be completed if the permit hfwro ohundred dollen
($100)nifess.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
Icenlfythatbthe pertor inn lis nwarkner outob Mapermit wbjeshsued, —
I shake not empty any person k any manner ass a to become subject to the WATER SYSTEM/TREATING
Worken'Compensatlon Gwa of Callfomk.Date PAID
O Z Applicant
Z O NOTICETOAPPLIILaRer making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFF. Date Recei t#
Fshouldbecomembject to the W.den'Comperuetlen pmvkiom of the Labor TOTAL:
N C.de,yourwatfanhwlthromplywlthsuchprovhbramthhpermltshallbe
> deemed revoked. G 6
CL C CONSTRUCTION LENDING AGENCY
SEISMIC
FEE L LTO
I hereby affirm that there is a construction lending agency for the perform TOTAL; ELECTRIC FEE
D O arm of the work for which this permit h issued(Sec.3097,Civ.C.)
oLo.dera Name PLUMBING FEE
LL t— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I nertifythat l have read thhappliatlonand stttetheitheabove Informatlm
a hcorrect.I agree to complywith al city and county ordinance's and mate laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives ofthti
H Z city to enter upon the above-mentioned property fee inspection purposes. ALTERORADDIOMECH. Date RCCCI t#
_ (We)agree to save,indemrdPfy an d keep Eaton.the City of CuCupertin
age Wt liabilities,I-dgrrcnt,coatsand expenses which may in anywayacaue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
aealn t Ity Jn 9ona errepoft ming of � i �O
AIR HANDLING UNIT(OVER I0,0)0CFM) CONSTRUCTION TAX
Sigrature of Appllant/.. tendIF mt. EKHAUSTHOODEW/DUCD CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappli est or future building occupant store or handle hazardous HEATING UNIT CM 100pW BTU)
mato al as defined by the Cupertino Municipal Code,Chapter 9.11,and the Date Recef t#
Health and Safetyc ction 15531(a)7 HEATING UNIT(OVER IBEEB0 BTU) TOTAL:
Yea o
Wllllhe appliant Nre building occupantuse equipment ordevices VFNIILATION FAN(SINGLE RESID) I$SLpLQC$DATE
which emit Exeardo a mkants as deRoed by the Bay Area Air QS
rGaq
Qality Management 1.7 aircontBOILER-COMP OFN OR 100,000 BTU)
ITS Yca No
havereadlhe hoar ous materials mquiremrnk under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) "jtlHA
the Glifamh Health&SafetyCode,Seal.ns25505,25S33and25534.1 9 v'' 3c071�J/
uMcretandlhatlfthebuildingdcesnotwur tlyhaveatenanLthatitkmy NEW RESIDENTIAL MECH. SQFf
responsibility to notify the occupant of the requirements which must be mot
priors once ofa I to DFO racy.
Owner or aulhwlud agent to
TOTAL: ISSUED BY: ��� V't:N/"'�•a—��V
OFFICE COPY