20542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PERNET NO.
Building Address: 20542
!21 o3 8,o Cl+S"' m E Av.
nevaone: A
•` TE?ER 09SARA TaNES aS7-; rrS CITY OFCUPERTINO-BUILDING DIVISION
Conradm'e .me: Lie.No: . APPLICATION /PERMIT
BUILDINGM.ECnUCAL PPL MBINGMEC MCAL CATEGORY CONTROL 0
Architect/Englnee�_ Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcae:
LICENSED
ICENSED CONTSDECLARATION
m
PFJ9TISSUANCE 1:1.V,JJrti Vms\s'
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❑
IhbUrnlhmimlkrnsounder mAPPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwthdiO7000)afDlvgonJoftheOug....
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Date
Conlndor
ARCHITECI'S DECLARATION 20I-I[XX)"PS
rc0 Z I understand my plans shall he used as public recent. OVER I ODD AMPS SQ.FT.FLOOR AREA $/SQ.FT.
obCOC
U Licensed Professional SIGNSELECTRICAL
N<N OWNER-BUILDER DECLARATION $PECULCIRCUIT/MISC
Z, 4 I hereby affl.that I am exempt from the Contradors License Law for the
following reason.(Section 70715,Business and Professions Code:My city or
FIi
F.µ9 TEMP.METER OR POLE INST.
� M countywhkh requiresapermlt rocantruct,al/eq Improve,demolkh,ar repair
Oanystmd mpeortoiak ame,al3omquimstheapplic ntfwsuchperMtto POWER DEVICES file a signed statement that he is limned pursuant to the provinces of the
sae Contrador.License Lav,(Chapter 9(mmmendngwithSection 7000)ofDhi-
3 slon3afthe Bug mmdProfession Cod.)orthehebeampttherefromaM SIN NG POOL ELECTRIC A�
en nt
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIXMtFS - Q
applicant for a pesubjectathe applicato a civil penalty of not more than
five hundred dollars($500). NEWRESIDFN77ALE1ECTR SQJE. STORIES TYPE CONSTRUCTION
(nn ❑I,as owner of the property,or my employees with wages as their sok
compeneadoo,willdo the work and thestructure 6 not Intended or offered for
Osale(sec.7046,Busimm and Professlan Code:The Contmet.es Limme Law
[ $ does not apply to rn owner of property who builds or Improves thereon,and OCC.GROUP RFS.AMTS
C; who doessuchworkhinuelforlhrough Maown employees,provided that such
Impreverrents are not intended oroffered forsele.If,however,thebuilding or TOTAL:
Impmvementi .ddwthnoneyearafmmpldloM1tMw er-budderwlllhave -
XX,rden of peerving that he did not build or Improve for purpose ofsele.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Q[I I,ae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cton to construct the project(Sec.7tM4,Business and Profession Code:
The Contractors License Law don net apply to an owner of property who �.�DRAIN&VENT WATER(EN
builds or Improves thereon, and who mntrace for such Iu jects with a FEE SUMMARY
cglRpdor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
L_I I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT'B
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOLTAX. Y N
❑I hereby.(firm that I have a mrlRcat,of concent to self-Insure,ora RECFJIrT a
cerifieste cdWorkars'Compensation lesamere ora nIfled copy thereof(Sac.. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab CJ
Policy p RECEIPT p
GAS EA.SYSTEM-OVER 4(FA)
Cam any BUILDING DIVISION FEES
�Certifed copy b herebyth thehnd. CREASPANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V Ned with the city inspection division.
CERTIFICATE OF EXEMPf1ON FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY S[O'RM EA 200Ff Date Recti HI
Rhbaedian neednotbecompldM iftheperMt lsfuronhmulmd dollars s
($100)orlea.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I cortifythat In the performance of thework forwhlch this pemdt is Issued,
I shall not employ any person In any rnnner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Uwe of California.Date PAID
Z
Z Applicant NEW RESIDENTIAL PIASB,_SQ.FT. Date Rett's NI
O NOTICETOAPPLICAM:H, m
this Certnicateof Exemptyou
should become subject to the Wododmn'Compensation provisionso(theLabor TOTAL:
LO Code,you must forthwith comply with such provision orthk permit shall be BUILDING '
EE !31 OD
LU > deemed revoked. -
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE '7
I hereby of i m that there is a construction lendlegagenry for the perform ELECTRIC FEE
Z an m of the work for which this permit le isasnd(Sre.309//,CIv.CJ TOTAL:
V O Tender'.Name PLUMBING FEE
LL I- Lender'.Address QTY. MECHANICAL PERMIT FEE
O W Icontify that l have read this application and nate that the above Information MECHANICAL FEE
1 Is correct.I agree to to comply with all dtyaM countyordlnanmand gate laws PERMITLSSUANCE FEES PAID:
>. W relating to building convection,and hereby authorlu rcpreameth,.of this
U) city to enter upon the abov cxcrtloned property for Inspection purposes. ALTER OR ADD TO MFCH. Dale Recel t#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V aga Int liabilities,)udgments,costs and expenses which may in any way same AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
.galt Id CI In con.ryue f the granting of this perm.
6—¢�a AIR HANDLINCUNIT(OVER 10,n0CFM) CONSTRUCTION TAX
Signature of Applicant/Contra' Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDO MATERIALS DISCLOSURE
Will the applicant orImum building occupant store or handle harardous HEATINGUMT(TO100,000 BTU) Date ReCCI CN
material as de0nnd by the Cupertino Municipal Code,Chapter 9.12 and the
Oes
Yaannd Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 8TU) TOTAL: ISA
Will the applicant airfuture building Occupant use equipment or devices : VENDTATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haenrdous aU contaminant.a.defined by the Bay Area Air
Quality Mangc.;A1st d2 BOILER-COMP OW OR 100,000 BTU)
4Yea No
have read the hex case meteriab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Section 25505,75533 and 25534.I lid 0 $ 199�j
understand that if the building doe.not currently have.tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. s
responsibility to rally the occupant of the requirements which must be met
prior oLssu nett cafe Ce 'f¢ eafOdvpanry. �C
Owner or authorlaed agent Date TOTAL SS Of
agent
OFFICE COPY
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