20493 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ca IdmJflcaJun PERISUT NO.
Building Address: 20493
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L"_-733q0I CITY OF CUPERTINO-BUILDING DIVISION
Contnaor'.N.me: yLk.Na APPLICATION / PERMIT 10
SYS` BUILDINGELFL'iAICALPLUMBINGMFGIIANICAL CATEGORY CONTROL.
Archlt glrcer� Lk.Na
Qy' Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. 31 b S —Sv PERMITISUANCE
LICENSED CONIRACSORS DECLARXTION
I hereby alfm,thatlam BcenseduMerpm WmsdC pmr9(comrrenc AFFLIANCFSRESIDENHAL BD N
Ingwlth Sectbn700D)of Div w3ufthe3udre.andPmfee Code,and
limn.la In wit fame and effect. PANELS
'Lkenec Clan Lk.Y
Date Contnaor LM102DUANIPS �C fes'`.. ✓
ARCHFFE(.TS DECLARATION 20l-I[K)()AJMPS
Weiql I uMerstaM my pismshall be used n public r ads, OVERHOOAMTS SQ.FT.FLOOR AREA S/SQ.Fr.
y`�j Licensed Pm fio Ai rsl MGNSELELTRK2AL
«6 OWNER-BUILDER DECLARATION �'s•LCIRCIIR/MLSC
�j 1 herebyeflmnthat lamexeenpt fmmthe Coad .rb Llarue Lawforthe
following reason.LSeCton 70115,Basin and Profembw Cade:Any tlty or TF7dP.ME7Qt OR POLE DIST. (�
rS, suntywh ,r qui .pe tomo cls atter,lmpmve,dem Wh,orreplr
Sey,"eam,prior to W Lwu ce,also requires the applicant foreach permit to MOWER DEVICES
an
1 Bk a s gned statement the he b hewed pursuant to the provisoro d the
fQS;wI{--� Contnaor'.Il¢me Law(Cluper9(cemmenang with Section 7000)of DWI-
dg�hg�p�LEPCIRIC VALUATION
F�OJ on Sof the Bu.lnes.and Profesiors Code)or that be b exempt therefrumaM
•77 the Wsb for the alleged exemption. Any NdaHon of Seaton 70315 by any OU7LE[SSISrI.ICFIFSEI)CfIIAES
QOL appBantfor&pemdt subect.jdada m
heappBmto•dAl penally dna
�{oF 0 undcd dollars($5M.7 NEW REMENIAL ELECTR SQFF. SILlRI6 TYPE CONSIRIICITON 1,an owner of the Property,or my employees with wages as their sole
Art! willdotheworkandthestructureiswtblended or offered for
O Tt 7054,Buske..AM Prdesbv Code:The Contractors Llumae Law
� $ daca nd.pply to an vwrsrdproperty who bulWs orlmpmves thereon,and
s^ whodmomh work hlmeeBcathrwgh Msownemplgm,provMMtAeeuch OC G RES.DNIT$
Improvements are not Intended oraffered fee vale.IL however,thebuliding or NOTAL
Impmve.ot bs wBblooneyearofcompletion,the owner-buBderwW have
tryLpoden of proving that M did one build or Improve fee purpose lamb.). QTY. PLUMBING PERMIT FEE
LJ L As owner of the property, u
am e.hlvely rentncJng with licensed D ZDNE APN
mntnctm to construct the project(Sec 704,k Buttressed[Prdessbm Code: PFnMTT NUANCE47
The Contractor'.LI¢rue Law don not apply to N owner of property who ��-DRAIN AVENT-WATER(FA)
bu BdaI r Improve therson, and who oritncts f¢such p(o)xb with a
�➢t[aaorW B¢nsed pursuant to the Contnaors Weenie Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L j I am evempt under Sec B 4 P C for this reason
roITSI DE FEES
DRAINS FLOOR ROOF,ARF.1,m SANITARY Y_ N_
Owner Dee RECFL7.
WORK MAN COMPENSATION DECLARATION FIX.[VREt PER THAI' TOIX.TA% Y_ N_
[✓Uf hereby efir.,ke rt that 1 have•¢Insurance
d.cerent to opytherm (Sc. RF�m'r a
¢niticab ofWorYen'Conparoelonlruunn¢caa¢rtBled copythareof(Sac. GAS F.A.SYSTEM-t ING40 FEE Y N
3800, 0 G)
Pdlq Y RECmT
Com nvmby GAS FA.SYSTEM-OVER )
y uJ1 BUILDING DI VISION Fr.ES
Certified copy,ish nIwth the city n - GREASE/INDUMMW FPTO PLANCHECK FEE
CcrtifiN ropy�(Tied with the city Inspection dlWJvn. '
CERTIFICATE OF IXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEVFR.SANTTARYSIORM EA 70(IFI' Date Remi f#
(Fhissectbn need nabe completed lithe permit lsfmorchundree dollar
($1ENERGYFEE Y N
00)cales.) WATER HEATER W/VENT/FZECIR
I¢elfy that In the perfomsn¢dUe work forwMch permit pedt b bored,
1 shall not employ any person to any manner n as,to become mb)ct to the WATER SYSTEM/TREATING
Woken'ke 'Compensation Laws,of CAlfonia. Dale PAID
O Z NOTICEApplicart
NEW RESIDENTIAL PLMB. SQ.FT Date Remi t>f
Z O NOTICE 70 MPLIGNT:If,ander rruking t his Certificate of Eaempbn,you
F N should become subkct to the Workers Comperoutlon proNsbro of the Labor TOTAL:
QCode,you most forthwith nomply wilhexIt promshal
provokes or dila peJt l be
W 5; deemed revoked. BUILDING FEE
CL E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemlay afHrmthat thereb a mmtruNon leMing agency for the perform ELECTRIC FEE
7 Z onceof the work for which dile permit is is.ual(Sec.3097,CW.C.) TOTAL
O O I<Mer.Narne PLUMBING FEE
F LaMer.Addmas QTY. MECHANICAL PERMIT FEE
O W Iesnlfythe l have nadtwm state thattheabosebJormatlon MECHANICAL FEE
E,mrrea.I agrtetocomplywlth allcityaM oauntymeltrunm and rote law. PERMIT ISSUANCE FEES PAID:
Nml.frigminfillingmmtmalm,and Mebyeathcab reprernhtIvesofthis
F Z citytoenterupontM above-m,ntbrM property for)ape ion purposes. ALTFRORADDTOMECH. Date Recci til
(We)agree to save,IMemdfy.n d keep harmless the Cky of Cupertino
V agaimtl bWties,ydgwntkm saMeapem "Lchrtsylnanywayamue AEt HANDLING UNI'r(I7010,000CFM) SUBTOTAL:
agalwsaid Cityto ...equeroe of the geeing of this pemdt.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signatureaf wppdcat/Contraetce Date r LIST HOOD(W/D[.C1) CONSTRUCTION TAX PAID:
. HAlARDOUSMATERIALSDISCIESURE _
Will the applicant in future building oevpant store orhaMle li—rdous HEATING UNIT(M 100,000 BTU) Date Recei Iq
material as defined by the Cupertino Murdapal Code,Chapter 9.17,and the
Ileand SafetyCM
hane,,,,Sal 25532(a)? HEATING UNIT(OVER I00XW BTU) TOTAL:
[ann Yes L T+Ga
ll]the appBant or future building oaupant useequlpmse or devices VENTILATION FAN(SINGLE RESTD) 47FAJ BICE DATE
whkh emit"mous air m��ambunu.as definad by the Bay Area Air 1
S Quality hfarugemem DlllJ—erI777 BOILER-002W OHPOR IOQ0008IM QQ�y
4 ca req JUN o z 1":9
hove read the hav Dile rtukrlais requirements under Chapter 6.95 o! BOILER-COMP(OVER t00,000 BT17)
the California Health h Safety Code,Se ime%75505,75533 and 75534.1
understand that if the building does not mrrently have atenant,that It is my NEW RESIDENTIAL hfEC-L SQFr __1t
responemBldydon ifytheocvpant a lu,requl dewhkh moms)be rust C4 of
( ,
'nor'nor to�uan¢o CeM6 ofuan¢o C<M6 of— Pa^cy. I ��+ar
Owner or authoJrad agent Data ISSUED BY:
rorwL — —
OFFICE COPY