20770 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USLL POINT PEN ONLY
BuildingProject Idemlfkatim PERMIT NO.
BalWjpgd e ¢ O l 20770
(1VCJ one APPLICATION SUTIMIIT7�=
CITY OF CUPERTINO-BUILDING DIVISION
_ Lk. APPLICATION I PERMIT
¢ BUII.DINGELECIRICALPLUMBINGMECHANICAL CATUGORY CONTROL
kea • glrcer. LIB No
If Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMRISSUANCE ❑ ❑ ❑
LTCE:NSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lfcen fiords,prwbiona of Chapter 9(. APPLIANCFSRE9 BDESCRB'DON
IngwlthSMbn7000)of eon3 ofthe Bu aydPm �ga�de,and
license le In(u41e dfeR. /v _ I /G1 h PANELS
LI¢ns,eC `+- lett J /J rr, Cnu'.5�j'�1C`AJ
Dale Contractor I
RCHITECTS DE N 201-10)DAMPS
ce0 T I understand my plane shall be used m public records, OVER 1000 AMPS' SQ.FT.FLOOR AREA $/5Q.FT.
O
z�j Licensed Professional SIGNS
�6 OWNER-BUILDER DECLARATION SPFLIALCIRCN
I hercbffl
yarm m mfrom the l aexempt frothe Contractors License Law for the
6Zk.
following...(Sectlm7mi5,Bualnes.ed Pmfesbns Code:Any city orNETEROO�JLE;NTV4p4E county which requlyd a perMt tomrutmt,alter,Improve,demallah,orreparranyatrutlurt prbrtoHalwrarc4alsrtqukntheappBmtlses,uch pemtlt tofile a algned eOtement that k le lic need pursuant to the prvwlons of the
Cnntntlare Lkeme Law(Clupter9(co.cing whit Secfbn 7DW)of Dlvl-alon3dtheeu.lneseandProf kmCode)orthathebemmptter mmaM VALUATION
the baab for the alleged exemptbn. Any vldation of Setion 70115 by any,S�,
�n LIl,dow"wll do the
property,o the
employed wahwdg.edor theiraok STORIES TYPE CONSfItfK170N
�t ok(Se.70Kw8l doth workandthe emte:TheC Intended or..Lofferecl for
❑ sale bee 70k4,Buelnem and Prdeaabm Code:ITn ContratloraEcense law
53 doe cot apply to an owner of property who builds or lmpr thereon,and OCC.GROUP RES,UMTS
GG whodmeuch work himattBrcthrough hleovn employees,pmvldN thatsuch
improvements are not intended aroffered for d.If,however,the building or TOTAL
Mpmvemmt beold wkhlnoruydrofcmnpltb4theowner-0uBderwi0luv<
t ,den ofpmdngthe h<db not build or knprove for WrPme ofvle.). QTY, PLUMBING PERMIT FEE
L.s owner of the property,am eachulvely contractlng with Beene, FLOOD ZONE APN
PERMIT ISSUANCE
ntraclon to construct the projectIS-,7014,Boanesaa rd Prdesbro e Cod
m
The Contretlora License Law dors not apply to an owner of property who ALM-DRAIN&VENT".WATERbuilds,or Imprwd thereon, and who contracts for such pV"with a
cQn{7�ctmG>u¢rued pur.uant to the Contractor.Ll¢rue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt u,dn Sec B k P C for this ramnOUTSIDEFFrS
Owner Dee
DRAINS R FLOOROOF,AREA,GOND. SANITARY Y— N
RECEqrr If
WORKMAN COMPENSATION DECLARATION FDCrURES�TRAP SCHOOL TAK Y_ N
-1I hereby affirm that I have a oertiliate d cmeent to se f-Insere,w
¢tBiate ofNforken'Canper eauon Insurance m•certified copy thereof(Sec. RECEIPT 4
3gW,lab C.) 1_0 GAS EA.SYSTEM-1 WG4OUTLETS PARKFEE Y N_
lakyly
/ - _ GAS EA. RFLER'TI
Ce v x�� / // BUILDING DIVISION FEES
1� u`rd M. GREASE/WDUSIRL WASIE IMFRCEVTOR PLANCHECK FEE
Certllied copy b filed with the dry Impectbn dh'Wm
ga` CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 7RM' I
PAID
V COMPENSATIONWSURANCE S'EWERSAMTARYSIORM EA 20OFT Date Reef tM
(Phis,section need rout be canplted If the permit Is f¢one hundred do0ara
I (flm)oc1e1e') WATER HEATER W/VENT/EFGTR ENERGY FEE Y N
I cetlty that b the pedomun¢dthr work forwMch Ihl.permK k trued,
I.hail not employ any penin Jr,any menne,as u to ecorn,subject to the WATEt SYSISM/TRFA77NG PAID
Worken'Comperuatbn Lwe of GBf¢nla.Date
z Z Applicant NEW RESIDENTIAL PCMB. 9OFT. Date Rete) Ile
Z O NOTICE TO APPLICANT:If,after euklng this Certificate of Exemption,you
should bemrri subject to the Workeri Compereatbn pro idoca of the Labor TOTAL:
CCN Cade,you rre.tforthwith cmnply with such powessom orthb pemdc shall be
CC
deexd revoked. BUILDI
W C CONSTRUCTION LENDING AGENCY ISMIC
CL Iherebyafflrtn that there b ut
a corrudion lending agency for the pedorm
FEE
7 Z an¢althe work forwhlch this permH bt edee(S3097,Civ.CJ ' TOTAL: ELECTRIC FEE
02 lender.N. PLUMBING FEE ay�
LL Lcoder.Addres QTY. MECHANICAL PERMIT FEE MECHANICAL FEE EW
O W1¢rtltythelhave mad thb.ppBatbnard Bate than the abwelnforrrutlan
b corray.Iagree to comply with all city and countyordloanmand state laws PERMIT ISSUANCE Z.0 FE•ESPAID:
0) rearing to building mrutrutllm,and hereby authodre repreentatives of this
Ztt oenter upon tk above-mentbrud property for inspection purposes. ALTER ORADDTO METH Date Recei toy
e)epee to uv mNfy an keap lurMes the City of Cupertlro
V BabBltld,lu me.a expend khmay In any we acau AIR HANIXlNG UNIT(IO l0,Ql0 CFM) SUBTOTAL:
a I Isald
Fit
r�¢oft this pemd. AIR I NDUNG UNIT(OVER 10,O0OCM CONSTRUCTION TAX
gnstum f p o tutor Lyle EXHALSTHOOD(W/DUCD CONSTRUCTION TAX PAID:
HAIEARDOUSMATERIA 9URE-
n%t=WOltheappli o r handle havrdaus HEATING UNIT CIO 100,000 IIM Date Recel tin _
l..deflncd yt a Cupertlw MuNdpal Cade,Chapter 9.17,and the
l-kalth.rdsfdy Code set ion zu3zWr HEATINGUNMOVER100,,000BTU) TOTAL: ,
I Yd No ��pp�
Olthe.ppilont¢ tore bu0dNg occupantuseequlpmerdadevirm VENTILATION FAN ISWGLE RFSBJ) Ie1'AAICF_.DATE
whkh eMt Fazsnloua.lr mntandranU.a dcRvd by find Bay Ama Ab "�f`�((�
allty,Marugemerit 7 BOII.FR-COMP OE1P OR IK(00 BTU)
t d
ere.d(heIt m edabrequimm ntsunder Chapter6.95of BOILER-COMP(OVER I MODO BTU)
t fmnbFkalth Sof • ode,Sectic.25505,25S33and25534.1 y��J
and slut fifth ' I g ora mrrentlyhaveatenant,thatitismy NEW RE3DFNITIAL MECH. SQFT. /4fi,
itY to nd tit p,nt the requ merle which moat ,ret `s,1 J of
mleu.na-d Ce f sof p. a, ref
' i i n 5be� no
run ar author) gent Date ������-p��
I„ I TOTAL ISSUED BY: --
OFFICE COPY