20988 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
1/,558 Cm pspt SpRiA/C7 CT , GupE2'PAjo - CA 9So/�G 20
988
aces: one: A
ner. Huy 7'H4&/H AJ6—UYbJ 2.53-fq CITYOFCUPERTINO-BUILDING DIVISION / p�
nn crus'.Naw Lac.Nm APPLICATION / PERMIT -lY
Ardatect/Engloee.. Lk.No: BUfLDINGELFGTRLCAIfPLUMBI GMECHAMCAL CATEGORY CONTROL X
QTY ELE RIC PE IT FEE BUILDING PERMIT INFO
Address PERMTTIS'IJAN ,Z ycl ❑ El ElLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am gcemed under provisions of Chapter9(mmmumc APPLIANC REST NTIAL JOB DESCRIPTION
It...h5ection7000)of Dlvidon3.(the Buslnessand Profedone Code,and my
limnx le In full force and dfect, PANELS
License Clam Glc p
Dale Contractor
AACHITECPS DECLARATION 701-IOW
q�q�uu 076 l understand my plans shag be used a public recods OVER] PS SQ.FT.FLUOR AREA f/SQ.FI.
Licensed ProfessionalSitG
�<<.4 - OWNER-BUILDER DECLARATION IAL CIRC T 75C
ZL, 6 1hm,byaffirmthd l amaxempt from the Contractor'sL=:.Law for the
Q (.Rowing reason.(Section 7MIS,Businem and Pmfe. Code:My dtyor
� �"' countywhlchrequiresapert twmr cis alter,impmve,dennlbh,orrepalr P.METER EINSf.
eeq,,'Qg any structure prior to its income,also requires the applicant for such permit to POSER DEVICES
O file a signed statement that he is Rmnsed pursuant to the provisions of the A 1A
30{� Contractor's License Law(Chapter 9(cemmendog with Section 7000)of Divi- SWIMMING L VALUATION
1 alon3 of the Buelneseand ProfeselonsCde)orthat heisexempttherefromand
the basis for the alleged exemption. My violation of Section 7011.5 by any OUTLETS-SWI
ES
applicant for a permit subjects the applicant to a civil penalty of nor morethan
a uars BISM).
nsown ofthepro NEW RESIDENTIAL SQ.ET. STORIES TYPECONSIRUCTION
�nd for
asownerofthee work a,ormy employeewithwages their sok
C c (Sce.pum7044,11.0willdthework.andtheatrutlurehe is C.susot.eot or License
La.
'S le(Sec.apply
to ahem and f property
rope ty Code:The C Improves Liceme hw
S$ cissa nocapplytork tmaelorthmag his
o nembuildorlmproovidedreoganat such -OCC.GROUP RES.UNITS
M whodoeantamerkMmsededomughhdowne.If,hoeiverthebuilaing or
Improvementsarenot Intendedearofcd!orale.If,h er-buOderlldingor TOTAL:
Improvement isnidwithlnoneyearofcompldioRtheowner-bunderwlllhave
tlIeturdeno(pmNngthat he did our bund orlmprove for purposeofule.). QTY- PLUMBING PERMIT FEE FLOOD ZONE APN
LJ 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEmote cton to construct the project(Sec 7046,Business and Professions Code:
The Contractor's License Law does nae apply to an owner of property who
.Linda or Improves thereon,and who centrads for such ptojecta with a ALTER-DRAIN k VENT-WATER MA)
cgIlllact )Ilmnsedpursuant tothe Cont,.doe.Lkerue Law. FEE SUMMARY
LI I am exempt under Sec B is P C for this naxam BACK FLOW PROTECT.DEVICE
DRAINS FI.ODR ROOF,AREA,COND. SANITARY Y N_
Owner Data RECEIPT R
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
C31 hereby affirm that I have• ncate.f consent to re,ora RECEIPT N
certifimteo(Workeri Compansationlmlaunnm ora mrtl(kd mpythepythereof(&c.
38 WLab CJ GAS EA.SYSTEM.]WCAOUTLE15 PARKFEE y N
,
RECEIPTM
Policy N AS EA.SYSTEM-OVER 4(EA)
Com ray - GBUILDING DIVISION FEES
Certified copy is hereby tumlehd. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 2110F1' Date Resi t#
(This section need d not be completed Blhe permit bforone hundred dollar
(SIM)us
les') WATER HEATER w/VENT/ELILTR ENERGY FEE Y N
I mrtlfy that in the performance o(thework forwhlch this permit Is asked,
I shag not employ any person In any manner an as to become subject to the WATER SYSTEM/TREA7iNG
Worken'C.mpenaation Gwso(Callfomla.Date PAID
Z Z Applicant NEW RESIDENTIAL FILMS. SQ.FT. Date Recei t#
Z 0 NOTICE TO enabjeAPPLICct to AM:IL aver rs'Comakirper Ctick preofemoftt eLabor
you
H ehde,youould ne aubthwith comply
Work en'such provisions
mthbvofthe tab be TOTAL:
N deemm!oumuat(orthwlth comply with such provisions or[his permitahall be
W dmmd revokd. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL C
I hembyaork f.c Ltlumicht isemat Is tionIssued
lending agency for.) perform- TOTAL: ELECTRIC FEE
M Z anmof the wore!or whkhlhis permit is laud($ec.3(197,Civ.C.)
V O L
ender'.Name PLUMBING FEE
LL F Lmder'.Addrea. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O WImdifythatlhavemadthisepplimtionand datethatthe abovelnf..ftr
ism
CL rrM.lagan to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and herebyauthorteerepreambitivesoHhis
F
city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? ,(We)agree to save,Indemnify an d keep harmleas the City of Cu Penton Date Recei t#
V against liabilities,Judgments,rode and expenses which may In any
I.� wayccru
e AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL'
aRabatsidl �tyin uem.f th .N AIR HANDLING UNIT(OVER lo,nocFn) CONSTRUCTION TAX
mqiOO
SpraturorA cant/Contractor I Tae EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIA DISCLOSURE
Will the applicant or future building ocmpant store or handle hazardous HP.ATINGUMT(TO1010,000B7U) Date ReceI t#
material as defined Who Cupertino Municipal Code,Chapter 9.12 and the
Health a rad Safety Cd a Ion 75932(2)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: x
�Wilthe applicant future building occupant use equipment or,devices VENTILATION FAN(SINGLE RESID) y5SUANCE DATE
whichemithazadous erontaMants as dened by the Bay Area Air !lK�M
Quality Management t 7 BOILER-COMP OHP OR I00,0M BTU) JIM*
4Yea o
havemad Health
a oils rCode,Se requirements and
6.95 of BOILER-COMP(OVER1W,000BN) S
the Gltand that tithe
building
Code,Sections 25505,25533 a Hand that 1 ,� - 71990
underesponsibility
thatn notify
the ingdms not erequtm meat which
thatb met NEW RESIDENTIAL MECH. SQ.Ff
priorL Iss to of theoate.fto(the requlrcmentswhich rrast be met CiqlZ�fty Vl Cuperdao
prior L issu ce of a C< IOcate o(Occv nry. T��]-�.��
ncrorauihm dagmt Date O - ISUED BY:
L7 I TOTAL:
OFFICE COPY