20719 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ing Address: •20719
I f kfL C 42SA N LANE L o-r It��
1 nes are: ._ ane:
Imes ~/ 2SS• 78 CITY OF CUPERTINO-BUILDING DIVISION D
ceno-ater.Na Lk. APPLICATION /PERMIT `"1
BLnDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
A ca/Engbuxr.
�• AEsrs.nl QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ® ® (d
I hereby.
ffirmthtEDCONTR under rDECLARATION
wIthSe ion7Dtlutlamlkm3ofthe usimnalonsof Chains ode,an ane APPLIANCES-RESIDENTIAL JOB DESCRIPTION
11...hSection 7000)of d o elon3ol[he Buelnemand ProfeWmaCode,and my
liana b in s form and tfect. PANELS
LicenseClam Lic.p
Date - ContntorUP TO 200 AMPS
ARCH ITECTS DECLARATION 701-1000 AMPS
rs0 Z 1 understand my plane shall be used es pub0c records. OVER 1000 AMPS SQ.FT.FLOOR AREA B/SQ.FT.
° �7 q( 7 Qz,
'Licensed Professional SIGNS ELECTRICAL �•
5 OWNER-BUILDER DECLARATION
�i SPFLL1LCItCIRT/MISC
owing reason.
ason.(hat l am 31.5,Business fromthe Conlnc flo License law fm the
�z"ppoo (oo which equines a per it toconsandr,Impro e, Code:Any city it /
ppTEMP.METFR ORPOLE IN (9
f ey countywMch requlresprior to s Issuance,
also
oreui es the aprove,demsuch,orrcpar J� �]
S 1 7 any assigned statement that
he I,licensed
pursuant to the povidone,or such ofpermit e roWFR DENIES ( V
file a signed statement that M b Ilmnxd pursuant to the pmvleiov o! the
Commences License Law(Chapter 9(commenMg with Section 7000)of Divi.
SWIMMING POOL C
tit0 slon 3 ofthe Business and Professions Code)or that he la exempt therefrom and VALUATION
<, the basis for the alleged exemption. My violation of Se tion 7011.5 by any OU7LRTI SWITCHESH I
applicant fora permit subjects the applicant tea dAl penalty t net more than L o
five l,.$cddoll.fthepIB. NEWRFSIDFM7ALELECTR ST. STORIES TYPECONSIRUCTION
�n Lf I,as owner of the property,or my employers with wage as their sole
comp.matlon,willdothe work andtheaructu e farm Intended or offered for IV —3
pale(Sec.7064,Business and Professions Code:The Contractors License Law +�-�- �N
�$ don not apply to an owner of property who build.or improves thereory and
^ who doessuch work himself orthrough hlsuwn employees,provided that such OCC.GRO RFS UNITS
improvements am not intended oroffered fineale.If,however,thebullding or TOTAL:
improvement6soldwithinoneyearofcompldtb theowner-buBderwill have
th�urden of proving that he did not build m improve for purpose ofsale.). QTY, BING PERMIT yD APN
U 4 as owner of the Property,am exclusively contracting with licensed ppSM ANCE
contractors to coratrut the project(Sec.7044 Business and Professions Code:
The Contractor's License Law don not apply to an owner of property wh
Wilds or Improve@ thereon,and who contracts for such pro)ects with a 'tib &VENT-WATER(FN
otTactor(s)Baned pursuant to the Contractor's Llmnel FE UMMARY
LJ I am exempt under Sec. B&P to this reason BACK 01'FGT.DEVICEIDEFEES
Owner Dae S-FLOOR,ROOP CO SANITARY Y N_
I WORKMAN COMPENSATION DEC ATION gCIdOO A% RECEIPT
❑I he
affirm that I have a certiflate of con est to nIf-In 'cr. FIXTURES PER TRAP
RECEIPT p
mrtlfiate ofWorken Compensgim Insurance ora Ifted copy the Mae. GAS EA.SYSTEM-1 INCA PA FEE Y N
3800,Lab CJ RF-j:=p
Co11ryM EA.SYSTEM-0 d )
Cm any BUILDING DIVISION FEES
Certlfled copy is hereby famished. G /wDusrw. L Erroll PLANCHECKFEE
Ccrtlfid copy la filed with the city W)xctlo divlsim.
CERTIHCATEOFIXEMPFIONFRO WORKERS• G ETRAP PAID /
COMPENSATION INSURA SANITARY-STORMEA IIID Date Remi t#
(rhlesetien need est becumplted If the Nrrrdt la forone hundred dollar10
(sIm)ammJIII•nTTB7w/vFxr/orcTR ENERGY FEE Y_ N_
I mrtifythat In the performance of the work forwhich this permit is issued, ;Loci il
I shag not employ any person in any manner n as to become subject to the WATER�,��/TREATING
Workeri Compensation Laws of California.Date PAID
-
0 Z Applicant NEW RESIDENTIAL FUME. SQFI. Date Recei t#
Z O NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you
should become subject to the Workers'Compewtmn provision,of the Labor TOTAL:
fA Code,you at forthwith comply with such provisions or this permit shall be BUILDING FrE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL c lending
I herebyaorkfthat Nerelsemmhutiondilm3agency 7,Civ. the perform- TOTAL: ELECTRIC FEE
0Z anmer's Name PLUMBING
which this permit la Issued(See 3097,CIv.Cd
U O Lenders Names PLUMBING FEE
1 LL F Lerder.Addrem QTY. MEC NICAL PERMIT FEE MECHANICAL FEE
O W Imdifythat l have readthis appliationand Yate thattheabove information
(LI bcot
nn .I agree to complywith all chy and county ordinances and Yate laws PERMITI ANCE FEES PAID:
>. N relatingtobulhdingmmtmdlm,adlarebyauthertmrepresentativnofthis
F Z city to enter upon the above,mentloned property for bapMion purposes. ALTER ADDTOMECH. Date Receipt#
(We)agree to save,Ind emNly an d keep harmless the City of Cu petition
V 7.
against liabilities,judgments,costs and expenses which may In any wayacnus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
raI cold City In con sequence of gran ng of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
/It
,fliSuture of Applicant/Contracter D e EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR DOUS MATERIALS DI SCLOS RE
Will the a pplicanl or future building occupant store or handle hamrdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as dented by the Cupertino Municipal Code,Chapter 9.1 7,and the HEATING UNIT(OVER 100,000 BTU) TOTAL:
Health and Sat de Section 755320)7
❑ No
Wilheappliantor turn building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamnlous air contamimets as defined by the Bay Area Air
Quality Massa 1Di Mt7 BOILER-COMP OHPOR I00,IX0 BTU)
Yca No
t havereadthehaaa msmaeriabrequimwnlsunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California I ImIth&Safety Code,Sections 75505,25533 and 75536.I
understa rad that if the Wilding don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
rnpomibllity to notify the occupant of the requirements which .at be met
to Lmua nce d a Certificate of ancy,
mer or authodud agent D.4
TOTAL: ISSUED BY.
OFFICE COPY