20584 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect lOswlflution PERMITNO.
Buflding Aj rear( .` (!!�)L(_ 20584
ners sore: I rhons; A
UTO CI rrC n CITY OF CUPERTINO-BUILDING DIVISION t ��y1.O
ontractor' Name: /^ U..No: APPLICATION 1 PERMIT l — "
• So:I C.. S� 0 — BUILDINGELE=CALMUMBINGMECHAMCAL CATEGORY CONTROL#
Arohtrcct/En riser. Pic.No,
" BUILDING PERMIT INFO =�
QTi'tR.. ELECTRICPERMIT F
Add.92 7 0a C,52S4 RING PFTtMITI56UANCE ..� .11 �,
LICENSE ONTRACTOWS D LARATION
I hereby aRbmthat l amlicansed under prwWonaof Chapterl)(mmmen APPLIANCES-RESIDENTIAL JOB DESC IION
Ingwlth SeY1on70DO)ofDlvldcet3oftheB"..dProfeWcuCode,and my
uxuele in loaf ane dfeci. /I/, (1 ^L PANELS �` \� \till
LlcenwC t `��+0-+�YfT
Date CoMsactor 4J'd(5/ YF/---
ARCNITECTS DECURATI N 20-IODO AMPS
n02I understand my plains shall be used u public records OVERIOD#)AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
CZE Licensed Professional SIGNSELFGTRICAL
n<w$ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC .
] 3 /hereby afflrlNt I am exempt from the CoNnctora Llrense Iaw forthe -
Zi. following reason.(Student 7031S,Busmen and Rofessbv Code:Any cry orTEMP. QRPOL'�^WSf.
I'..�
muntywhichnqubeeapemdttomnetracyalter,lmpmve,de=bsh,orrepalr ,.
4 Yro anymprlortoltsbwawe,alwlen
mqulhaappBuntfmmchpert itoPOWE ..
file a signed statement that he Y Licensed pursuant to the provisbu of the DEVItSS
q�• Contneteri Lbeue Lsw(:hapler9(commsencing with Settbn7000)of Divi- Swwlh4GPOOL ELECTRIC
j05 alon3 of the Budneuand Prnfesilens Code)ar that hebeumpt thercfwmand / VALUATION
lx
the basis for the alleged exemption. Any Wolation of Section 70115 by any OUTLETS.
applicant fora permit subjects the applicanttoa civil penalty of not m mthan ll
five hundred dollar DSDD).
3 F1 L as owner of the property,or my employees with wages u their sole NEW RESIDENTIAL ELECTR SQFI. STORIES TYPE CONSIR CUON
_2pQ compesurtian,will do the work,sod the structure ti not intended or offend for
-❑O sale(Sec 7011,Bushes.and Profeolero Code:The Contractors License Law
$ does not apply to an owner of property who bull"or improves therton.and OCC.GROUP RES.UNITS
whc doessud,.rk himself or through his own employees,provided that such
improvement+are not Intended or offered for sale.If,however,the building or TOTAL
Improvement is sold whhh meyearo(comptimm,the owner-builderwill tuve
t Nen of proving that he did not build or Improve for purpose of sale.). 'Q'jy. ,;ur;�-.PI.UMBINCPERMIT_';e" ''•FEE"; FLOOD ZONE APN
U I,es owner of the property,am exclusively coremUnI,with 1lcensed PERMIT ISSUANCEowtrattma b mrulrud the project(See 70K Businm and Prolenbns Code:
The Cemnctora License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
bulls or Improve themes,and who corms cis for such plojecrs with a :I v t•'• ,amu r
�BIT+cior(s)homed pursuant to the Contractor(License Law. BACK FLOW PROTECT.DEVICE '•'c �}=<I._.,PEE'SUMMARY.v c_ „ ;.'}+'
L exempt j I am ea under See B&P C for this reason
Owner Dm
DRAINS FLOOR ROOF.AREA,ODND. SANITARY RFGFRT#
WORKMAN COMPENSATION DECLARATION
aRbm
pI hereby that I have a certificate of consent to self-bwrt,or a FD(IURFS MT�e SCHOOL TAX RECEIVEN#
38W LaeofWorkeai Campewdwlnsunnceoracertlfled mpythereo(f0ec. CASEA.SYSTFAI-1 WG#OUTLETS PARK FEE Y N
3800,Lb C.) 5-9-32—
Ibliq# P. DING DI#
���ppp+aa GAS F.A.SYSTEM-0OVER BUILDING DIVISION FEES
C.
Inifird copy is hereby furnished. PLANCHECK FEE
❑Cenviee copy 11 filed with the city wpectbn diviYon. GREASE/INDl1SIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM F.A.2OOFT Date ReCCI til
(Thiaseciion need nu te,completed lithe permit b forom hundred r dolla
R100)orlm3 WATER HEATER W/VEM/FLFL I.R ENERGY FEE Y_ N_
I mrtlfytlul N Ne performance o(the work forwhich this perni t is Issued,
I shall not employ any penin M any manner w as,to become abject to the WATER SY5[EM/TREAT(NO PAID
Workers Compensation Laws of California.Date
Applicant Date Recei til
QNOTICE TO APPLICANT:If,after making t his Certificates or Exemption,you NEW RESIDFMUL PLMB. SQFT.
should beconns subject to the Worken'Compensatbn provisions of the Labor TOTAL:
toy Code,you at forthwith comply with such provisions or this permit shall be BUILDING FEE CX)
LI `J dremed rooked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE t LIQ
L C Ihercbyaffirmthatthercbaconrtmction lendingageNyfarthe perform TOTAL: ELECTRIC FEE
D Z ane el the work for which this permit is Issued(See 3097,Civ.C.)
O iander;N,me - f- -I. PLUMBING FEE
L F lenders Addreu Q7Y: y`' MBCHANICALPERIvIIT
' ` - FEE'' MECHANICAL FEE
U Icertitylhallluvereadthbapplicatienand wtethattheabowirfo.r.1.
LU C. bcorrte :
.I agree to complywith all city and county ordleanresand Yate laws PERMIT FEES PAID
W relatingtobuilclug construction,and herebyauthorlu repnesentalivnof this
Z dtylc enterupon the ahove-mentioned property for Inspection purposes. ALTER OR ADD TO MUCH.
_ Date Recei ted
(ner ages to save,enemnity and keep harmies which
the 1.a of y.q.Cupertino
� againstllabWtin,jrdgmew,costs and expenses which may In anywayaeplre AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Inst said City Inen¢of the gram r
Ing of this permit j .e/9AY��J 64- Deis
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig me(Applica //Contractor /�[HDeis EXHAUST HOOD(W/DIKn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Yore or hand le haaardom HEATING UNIT(TO 100,000 BTU) Date Recei til
material as defined by the Cupertino Municipal Code,Clupter 9.12 and the
Health and Safety Code Section 2S533(a)7 }{EATING UNIT(OVER 700,000 BT V/ TOTAL:
n❑
Y.
No
`t•Villlhe appllesnt car(utvrcbullding occupant use equipment car devices VENTILATION FAN(SINGLE RFSID) .J$$11A1iICE DATE
which emit haeardous air comaminentsas defined bythe Bay Arca Air . ��!
Quality Management Dislritt7 BOILER-COMP OHPOR 100,DMJIM
Tian glNo
have read the haaa oils materials requirements underChapter Q95 o! EOR- COMP 100,000 BTU) jU:\
the California Health&Safety Code,Sections 25505,25533 and 25536.I
undenta rad that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ7T.
responsibility to notify the occupant of the requbemenls which must be mel 4 a C el Lino
prior to lYuance o(a Certifiale o(Occvpamy. Cllf 71
_ �� ••����� ���--�� a
Owner or aulhoYaed agent Date
TOTAL ISSUED BY� y`�C
OFFICE COPY