20267 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Address: 20267
!'
166,60 Z NZA L�.CVd
mer•llsrmw one.
p'PFLX—�- CITY OF CUPERTINO-BUILDING DIVISION c3..
O& �O O y�Ny APPLICATION I PERMIT J�d `v
BUILDING-ELECTMCALPLUMBINGMECIIANICAL CATEGORY CONTROL N
Architect/Engineer: Lic.No:
y�� ,_/I�s �M ( _�/w�QI Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
_s�NN A1 ��"^'+Q PFRMBTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chaplar9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTIONingwlth Section 7000MDivision 3ofthe Buslrassand PrefesslonsCode,and my
Llanecie�W!(pa�jnd leis«. eJ �/ PANELS
Date4sb/a7L'—Contnct�or L T [��/��' `J '_
!!nderst ARCHITECT' CLARATION —'T/• p OVER
1000 � C`
IXO ZO I urderetand my plain shag be used o public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
od0 Licensed Professional SIGNSELECTRICAL
�]4� OWNFR-BUILDER DECLARATION STFLALCRCNT/M>r
2 f,Yd Za Iherebya(firm Ratlam exempt(romthe Contractors Llcenae law(orthe _
p j: following reason.(Section 7031.5,Business and Professions Code:Any city or
2
O TEMP.METER OR POLE INST.
county which requires a perrrdt Wconstruct,alter,Improve,demolish,or repair
4any structure prior to an Issuance,also requires the applicant for such permit to POWER DEVICES
P file a signed statement that he Is Roamed pursuant to the provisbv of the
G61 O Contractor's License law(Chapter 9(commenMg with Section 7000)of Divi. SWIMMING POOL ELECTRIC
sion3o(the Buslnessand Profeniov Code)orthat he kexempt Nerefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7LE•IS5WI•ICIIESFI%•I.URFS
0a5 applicantfor&permit subjectsthe applicant to a civil Penalty clout morethan
Bk undred dollars(5500). NEW RESIDENTIAL ELECT6R
SQFf. STOWGS TYPECONSTRUCTION
�a I,as owner of the property,or my employees with wages as their so
t mmpensation,w0l clothe work aadthestruchme Isom lnteodedar offered for
5 O sale(Sec.70K Busbam and Pmfeaslaro Code:The Cmdrac afs Lim.Lw
�RR does net apply to an owner of property who builds or improves thereon,and OCC.GROUP RI3.UNITS
whodoessuchworkhimself ortheaugh hlsownemployees,provided that such
Improvements are not intended orof(ered forsale.It,however thebuilding or TOTAL:
improvement issold within oneyearofcompletion,the owner-buaderwlll have
tfr�rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U I,as owner of the property,am exclusively mntraning with u-r— PERMIT ISSUANCE I
contractors to construct the project(Sen 7094 Business and Professions Cade:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER[EA)
baud. or contracts thereon,and who contrafor such projects with a FEE SUMMARY
cgpJpContractorsaw
aor(s)licensed pursuant to the Lim..L . BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B k P C for thin reason
,.
Owner 0 DRAINS-FLOOR ROOF,AREA,LAND. r/` s� SANITARY - Y N Date x-1
RECEIPT N
WORKMAN COMPENSATION DECLARATION FDCEURES PER TRAP SCHOOL TAX Y N
Ql hereby affirm that I have o tt suram of consent m self-insure,ora 2( BBC=
ttW,I. of Workers Compensatlonlnsurentt ora ttrtl(kd copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUILEM I ✓GC6 PARK FEE Y N
policy ■ Q 9�y GAS EA.SYSTEM-OVER DINCRECEIDIVISION
CIITom�p1"zany s`af_Q �L�P � BUILDING DIVISION FEES
elate copyishere rnlahed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Cer/Bied copy Is tiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Datc Remi t#
((his stolon need not becomplcted lithe permit Isfor one r
hundred dollars
(5100)mless.) WATER I-IFATEI(ty/Vpxr/ELEern 1^�(� ENERGY FEE Y N
I certify that In the performance of the work for which this permit i.Issued,
I shall not employ any person In any manner so u to became aubject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California. Date PAID
Z ZNOTlicant
ICE TO APPLICANT.ILaRer making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FI'. ' Date Reml t#
D should became subject to the Workem'Compemattonpmv Wmofthe Labor TOTAL:
N Code,you must forthwith comply with such provisions marts permit shall be
BUILDING FEE
W 7 deemed revoked. .
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmthat there Is a construction leadlegagency forthe perform- TOTAL: -LECTRIC FEE
D Z ancuafthe workforwhlch this permit Is Issued(Sec.3097,Civ.C.) s
V O Under'sName PLUMBING FEE e
U. F- Lenders Addrea. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
W lmnifythatlhavercadthlaappBotionand.tatethattheabovelnformatlon
O
CL Jammed.I agree to complywith all eityand countyordlnances and elate laws PERMIT ISSUANCE FEES PAID:
>- relating to building mnstruction,and hereby authodze representatives of this
W
[_ W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD 7O MECH. Date Reeei t#
(We)agree to save,indemnify an d keep harmless the City of Cu Parton
V against liabilities,judgments,cote and expenses which may In anyway accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL'
against said City In consequence of the granting of this permit.
AIR FBANDLING UNIT(OVER]0,000CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Reml t#
material as defined by the Cupertino Municipal Cade,Chapter 9.1 2,and the
Health and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: B
❑Yes ONO
Will the applicant or future building occupant use equipment or devices VENRIATION FAN(SINGLE REBID) [$,SJ, I�E DATE
which emit hazardous air conte mlrants as defined by the Bay Area Air Q.a�{aJT
Quality Management District? BOILER-COMP DE'OR 100,07 BTU) J
4 Yee No
Y.
read the hazy nus materials requirements underChapter 6.95 of BOILGR-COMP(OVOt IOO,000BN) i�,"1
the Gllfernu Health k Safety Code,Sections 25505,25533 and 25534.1 l,r. ( e.
understand that it the building does not currently have a tenant,that It Is my NBW RESIDENTIAL MECH. SQ.FT.
responsibility,to notify the occupant of the requirements which moat be met ^+ Plinv l Intl
prior to hauance of a Certificate of Occupancy.
Owner or authorized agent D.tf
TOTAL: jF"ISSUEDBQe "'�`*"' mob^
OFFICE COPY