20556 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY /
Building Projed Identubtim
con
v N'TS 2 i L PERMIT NO.
Building Add : 20556 O r 5nu
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CITY OF CUPERTINO-BUILDING DIVISION
u'K-dlJ U-"
cmtst«•C Name: Ix.Na: APPLICATION / PERMIT
rch . BUM.DINGELECTRICALPLUMBING-MFLHA NICAL CATEGORY CONTROI.I
ARe t/En over. 1e LNa
Q ELECTRIC PERMIT FEE ' BUILDING PERMIT INFO
Address - FERMITISSUANCEEl ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that l am lkomed under P.1sion.of Chapter 9(commm APPLIANCESRESIDENITAL x30 Dt,CM
Ing Floe.h5eebn 700D)of in.and elft on3otlheBusiness and Pro(eWmeCode,and my
Lias ebIns roan and skeet. PANELS
Date ��. 7 croon —2215C,2: n_M�chanical PLUK R
Date 3/-ylj—Contractor
ARCHITECTS DECLARATION 701-1000 AMPS
QQZ IuMea Mmyphmah Ubeusdupubhciewds OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
o[j Lio,mad Professional SIGNS ELECTRICAL
6y OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/MLSC
Ihereby.ffirmthat l.mexempt fromthe Comaatarb License law f«the
following reaem.&dim7MI5n.,Bualnand Psofuon M
loCode: y city or
OpplI"' n which Inesatommtrut,alter,lm mvpdemolb r TEMP.MEITR OR POLEIMT:
FSO anytmeua prior to its bsuame,also requires thea pliant for such permit to
5 O
fife a aigned statement that he b Bamsed pursuant to the powlamne of Ne POWER DEVICFS
Contatore L,eme Law(Cha(Chapter e
nenn S
withrtlnn7000)ofDivl-
�O�' abn3ofthe Wsines.and Pmfmbm Cods)onthat he b �
e therefromand SWE�fMINC POOL ELECTRIC VALUATION
'g the bub for the Akged exemption. Any violation o!Secctlon7m15 by any
cep Q apph.ntfora pemdt objets the applicant tore Evil penalty dna morethan OU'TLEISSWI7CFIESFlXTl1I4F5
h Eve hundred dollirs(55M.
6 n 1,u owner of the property,or my employees with wages u their sok' NEW RIDDFNTIAL Ef.ES"TR SQFI'. STORIES TYPE CONSTRUCTION
compensation,wRldothe work,and the cot
uure b rot W ended or otlemd for
5 0 sakLSec-7004,Business amiProf®loro Code:The Comraeoes License Law
(,IrQ daanwt.pplytoanownerofpmpenywMWU@orimprovatherto ami
C• whodoneuch workhlmeell orthmugh hisownemplgen,prwkled that mch OCCCROUP RMUNTTS
a Improvement.uunotmtendedorofferedforule.If,hcwever,thebulldNg« TOTAL
Improvement Is sold wkhln ane year.!completbrc the owner-0uilderwl0 love
t4LIIu rdenofpmvingtw hedid me WEdorimprovef«purpssofsale.). QTY. PLUMBING PERMIT FEE
LI L u �
owner of the property,am ershmroly tratpa
ing with parsed PERMIT
ZONE APN
PERMIT ISSUANCEmntraton m construe the pSer.)et( 7014,Bovines and prdn.lors Code:
a The Contaeori Llanx Law don not apply to an owner of property who ALTER-DRAIN A VFM-WATER TA)
or toy.thereon, and who comate for such pjets whitsa
ry➢1(+tor(q ucemad pursuant to the Contractor'.License Law. BAacEwwFRQTErT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B A P C for thb reasonOUTS I DE FEES
Owner- Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION` AECFR'T a
. 07
hereby affirm that I have a oertl0cate of consent to.elf-Iwre,or• FIXTURPSPFRTRAP SCHOOL.TAX Y_ N_
cenlEate of Workers'Compensation Insurance«a certified mpy thereof Fac. RECEIPT
3800,Lab CnJ��nQ(yQ��q GAS EA.SYSTEM-1 WC40UlLE15 PARK FEE Y_ N_
CoPolm a renuaau 1.+r5. GAS EA. I'Q.f-0VER4(EA) RIN�a
' Cy BUILDING DIVISION FEES
Cewled copy is heabyth thehaa. GREASE/IArIXIsnu,WASTE wTERCl-POOR PLANCHECK FEE
ertNed mpy Is(tied with the ttylrepectbn dfvbim. '
CMTUJCATE OF EXE1.11PHON FROM WORKERS CEEASE TRAP PAID _
COMPENSATION INSURANCE SEWER-SANEEARY,S ORM(EA.XpF-r. ' Date Recd t#
( orlecibn need not becompleted Rihe permit b!«as hundmd dollars
rnm)«les.)
WATER BEATER w/VENT/ELETR ENERCYFEE Y N_
1 cetuy that b the per(ormnce of the work forwNch tM.pemdt le Iwed,
I ehaB stat employ.sty penin In any manner eo u to bcmme objet to the WATERSYSTEM/TREATING
w«kea'compen„mnlaw.cur CaWamla.Date PAID
PP
A Ilan,
Z =O NU
OTICETO APPLICAN(: ,after making thbrtB
Celate of Exemption, RESIDENTIAL PLMB.
n,you SQ}T. ee
Dale Rd t#
.amid become aubjet to the Workers'Compersatlm proWslom orthe Labor TOTAL
N Code,you mist forthwith comply withauch pmvbbroorthb permit shall be BUILDING
W 7 deemed revoked.
CONSTRIKTION LF2gDING AGENCY S ISMIC FEE
CL Ihereby afBrtnthat there b•mmeroeion lerdingagency forthe perform ELECTRIC FEE
Z ance olthe work forwhkhthb psmdtls ,c.ea,ed 033097,Civ.CJ TOTAL: xZ
U O I,ruler',N.me PLUMBING FEE _
LL ~ leoder'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OIU Icertlfythxlhave read thbappgotbnaM aahthatthealxwe Wamvdon
1 Eson— -Iagreetoccenplywkh all ttyaM ommyordbancesand state laws PERMIT ISSUANCE FEES PAID.
r r,Iallog tobullding mvtrution,and hereby authortre mpreantatWn ofthls
Zcity to enter upon the above-rmntlored property f«bupetlon purpus. ALTERORADDTOMECH. Date RecCl t#'
V — (w'e)agree to save,indemnify an d keep harmim the City of Cupertino
against OabWtka,ydgments,m+t.am expenses which may N anywa .e AIR HANDLING UM1TT(TO 10,000 CFM) SUBTOTAL:
agalut said City In mosequeme of the granting of tM.pennR. AIR HANDLiM1G UNIT(OVER 10,070 CIM) CONSTRUCTION TAX
YJ
Sgvmreof Appuo t « Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7AR15OUS MATERIALS DISCLOSURE
Will the appliantorfuture building occupant store or handle hazardous HEATING UNIT UO 100,000 BTU) Date Recei t#
material as deEmd by the Cupenlro Municipal Code,Chapter 9.17,and the _
Fkalth and Safely Code Salon 25532(a)7 HEATING UNIT(OVER IW,"BTU) TOTAL: x15
YnI` No
WW the applicant tum Wilding occupant us equlp.ru or civ VENTILATION FAN(SINGLE RFSTD) IS511AtyDATE
which emit hezardsue air contaminants as deEnd by the Bay Arca Air ��iN�1LJ
• Quality Management Distrkt7 BOILER-COMP DEE!OR 100,000 BTU)
yesNo
Thave madthe hav •materials rtqulremenb under Chapter b.95 of BOE.FRLVMP(OVPRIOO,(00BTU) .JUN E 6 19SU
the Ca)ffom6l Iealth 6 SafetyCode,Saabs 2"505,75533 and 25534. I
understand that if the Wlldlogrims not currently have.tenant.that It bony N'EW RESIDENTIAL MECH. SQ.FT. City r,B�Blt
.possibility to notify the o pm ch m
reof the requirement.which be met
prior to Issuance of a Certificate of Occupasry �j111e + .C
'CAvner or authorized a get Date TOTAL: I I
ISSUEDBY:
OFFICE COPY