20861 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject ldemifkaiuo PERMITNO.
.. . Building Address: 20861
10 50 'g-Es Pales D;- z z- 71
noramu: one: A A A
t 4. CITY OF CUPERTINO-BUILDING DIVISION
Contractor'sName: L(c.No: APPLICATION I PERMIT
sv -111a BUILDING-ELECTRICAI PLUMBING-MF LAICAL CATEGORY CONTROL M
Arc Itect/Engineer. Lk.Na:
QTY ELECTRIC PERMIT FEE -- BUILDING PERMIT INFO
Address: PERMITISSUANCE 0.a � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION o(C ION LP
I hingwithSy that I)oM Bcen3oftheunder
usirododo!Chews (co.mom APPLIANCES-RESIDENTIAL ]OB DF9CRB'TION
Bomseh In fun force and
fficE (the Businesaand ProfesslonsCcode,and my
license la In fulf torte dna erred. rnNos
License Ctass Lk.p
Date Cont.ctor x++Wrt b
ARCHITECTS DECLARATION 201-1000 AMPS
O ZOCC I understand my plans sFeB be used as public records OVER 1000 AMPS Y SQ.FT.FLOOR AREA $/SQ.Fr.
Ob U Licensed Professional SIGNS ELECTRICAL
<� OWNER-BUILDER DECLARATION g+FLIALCIRCUIT/NEST
Ihereby of rm that l amexerept from the Contrador's License taw for the
Z
O/.9 following reason.(Section 7031.5,Business and Professions Cade:Any city or
c.µ9
county which rc<Puircsa permhtocotutruct,alter,improve,demolbh,orrepalr
TEMP.METER ORLE INST.
q � anya signed
statement
that
he is also sed pursuant t the Provisions
of t e POWER DEVICES
E 0. ilio a signed statement that M b Ilmnud pursuant to the provlslom o! the
O Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- r
�0� alon3cfthe Business and Profession Code)orthat he is exempttherefximand SWAIMING L E C�, VALUATION
Yd the basis for the alleged exemption. Any violation of Section 70315 by any dAN
< aprBcant fora permit subjecutheappllcanttoacivil pevlty of not than OUTLETSSwI b �—
afive ndred delta.($500). \ NEW RESIDENT]
�n 1,as owner of the property,or my employees with wages as the sole `"Q'FT' STORIES TYPE CONSTRUCTION
c penaatlon,w0ldothe work andthe structure Is net Intended or offered for II
aO sale CSec7044,Businessand Professlona Code:The Contractors Liceme Law
�,IS$ does notapply to..owner of property who builds or improves thence,and
CC.• whodoom.rhwork hlmseforthreugh hisownemployeea,provided that such OCC.GROUP RES.UNITS'
Improvements are not Intended oroffered forsale.If,however,thebullding or AL;
Improvement hmidwithlnoneyearofcomplet mtheowner-bu0derwill have
to enofpmvingthehedidnot Wudorimpmveforpurposeofsk.). QTY. BING PE M FEE ELODDWIF APN
ISI,as owner of the property,am exclusively contracting with lirensed ONCE
cont ctorsto ronstrua the project(Sec.7044,Business and Professime Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VELA-WATER(EA)
W ikls or Improves therms,and who contram for such pkojeaes with a
01 ctorec(s)Housed pursuant to the Contractors License Law. BACK Flow PROTECT.DEVICE FEE SUMMARY
L)I am exempt under SB k P C for this reason
OwnerOUTSIDE If
DRAINS FLOOR ROOF,AREA,CONTE SAMTARY Y N
Urate RECEIVE M
a KM MPENSATjWNDFCLARATIO FDcniRFS .fir SCHOOL TAX Y N
❑I hereby affirm t t have a mrtiHote of consent to self
-Insure,or a
comflcam ofWorkers'Compence
anton Insurance ora mfled mpythermRECEIPT Nf(Sec. GAS EA.SYSTEM-1 INCA 3800,Lab CJ PARK Y N
Policy rl RECEIPT p
Com any GAS EA.SYSTEM-OVER4(EA)
�Certlfied copy Is hereby famished. BUILDING DIVISION FEES
❑Certified copy isfiled with the city Inspection division. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF"EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhlssceton need not M completed if the permit ix for one hundred dollare SEWER-SANITARY-STORM EA,200FT. Date Recei t#
($100)certify
J in WATER HEATER W/VENT/PT TR ENERGY FEE Y N
]certify thatoy mp person ance
Ire work an so toIsmo Paermitls towed, —
1 shall not employ any person In any canner at u to become wbject to the WATER SYSTEM/TREATING
Worker%CompenoCalifornia.
tion laws o/ Date PAID
O Z Applicant
Z O NOTICE IO APPLICANT:If,after ma king this Certifkate o(Fxemptlan,you NEW RESIDENTIAL PLMB. SQFT, Date Recei t#
should become subject to the Warkers'CompetuaUon provision,of the Labor TOTAL:
er In
Cade,you—Itforthwith comply with such provisions mthis permit shall he 39
LU > deemed revoked. BUILDING FEE t,
CL o CONSTRUCTION LENDING ACEVCY SEISMIC-FEE a
I hereby affirm that there ta a onsumuce lending agency for the perform ELECTRIC FEE
Z ance olthe work forwhlchthis permit u Issued(Sec.3097,CIv.C.) TOTAL: r
U O <ndera Name PLUMBING FEE
IL F Lcnaers Aaareas QTY. MECHANICAL PERMIT FEE
O W Imnify thatl have read lhbapplioHonand statethattMECHANICAL FEE
heabove ln(orrrutlon
1 bmrret.I agree to comply with all city and county ordinancesand nate laws PERMIT ISSUANCE FEES PAID:
r N relating to building conalmonon,and hereby authmom representatives ofthta
H Z city to enter upon the above-mentioned pmpeny for inspection purposes. ALIERORADDTOMECH.
— (We)agree to save Indemnify an a keep harmless the City of Cupertino Date Receipt#
against Babllltiss,judgments,mssand expenses which may In anywayaceme AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
against said City in en otthe granting of this permit.
�/['[.�/99 AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigmture of Ap Tom/Co encern 'QatA� IXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD S MATERIALSDISCLOSURE
Will the applicant orfumm building occupant game,handle hazardous HEATINGUNT(T01M,030THLB
mmuri.iasde(inedbythc Cupertino Munlcip.l Code,CharHer9.IZ..dthe _ Date Recel t#
I leahh and Safety Code,$envie.25532(.)? HEATING UNIT(OVER 100,000 3M TOTAL:
❑Yes jr'f-1—q_fJo
Will the applicant c future building occupant use equipment or devices VFNII LATION FAN(SINGLE RESID) ISSUANCE DATE
which emitm ban moair conta emnants as defined by the Bay Arca Air
Quality Management District? ,0W RTU)
T Yes No p q s®
have mad the haze et materials requl 25505, 5533 and
o! H!n—,
COMP v-6�Vi 1
the California Health k Safety Code,Section 7550.5,25533 and 25534.I
understand that if the building does not eurcntly have.terms,that it is mysQ.FL p Va r+ � 1990
responsibility to not lfy the occupant of the requirements which most be met u
prior to issuance of a CertlRcete of Occupancy. /�pQ�n -
authorized rag /Date �'4P.Y Pf Ras�4y�:pEn
TOTAL: ISSUED BY<` '^'"� R'
OFFICE COPY
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