20964 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
riomilos Imes Wentif"tim PERMIT NO,
Building Address: 20964
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vrDe amo. one.
CITY OF CUPERTIN&BUILDING DIVISION
c aff /7� / Na APPLICATION /PERMIT �1 1 h/ Y£ O / BUILDING¢ECIRICM4PfA1MBING-MECHANICAL CATEGORY CONTROL
Archhee/lagfreer. Glc Na�
'QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
/ Acidrt.ac,
PFRA9TISSUANCE Elfk71 1:1LKENS ED CONTRACTORSpr DECLARATION �J
Ikreby arlirmtlut lam lkvunder eed caerrprovisions ofCheper9(emnvvaine MIs11ANCESRFSIDFNITAL JOBDESCRITTON
Ingwlth5ect1ul);Mp)a die•Itlon3 ofthegu.ineseabu Pmfestloru Code,and
"ccEse b In fu and eflect PANELS
Llce C s ' Lk Y - 6 - P"T� �� �
D Conwctar
ARCHITECT'S DECLARATION Mi-i"A
µqqWt ovaw, I wtderatand my plans.hsl be used u public records. OVER1000A. SQ.FT.FLOOR AREA S/SQ.Fr.
E Z
Licensed!Rofevbvl 9CNS
< OWNER-BUILDER DECLARATION SPCCUL - r
Ihmbyaffirtnthatlamexemptfmmthe Contractors Lice "wfmthe
'n fol owing m..(Section7MIS,Bu.ln®and Prafeabv Code:Any city or
F ., cuuntywhbhrequ4 apem wmvtruct,alter,lmpm ,demdbh,orrepair P'
Ldufile a
atnymrruumpmtolbame,ahrequsthaeapottif0
� ptplfwchdt
CentatloLk.Law Chapstatement t1had he Is ter with
sbn3afthc Business Pm(.bnsCaie)mUt hobf eupthm
-
VALUATION
heba.bfortheillegeds.emptbn. MyWdatlono
SaYlon 7¢f 15 by any r�
<i applcantfora permit subjeciatheapplicaettoa civil penalty ofnd more than
c. fluehundreddollane( riM). t RESm
❑1,as owner of thepmperty,or my emplaye with wage as tklr sob S'pr' =RIES TYPECONSTRUCITON
76 compensedon,willdothe wvkandtheetruGure brmt LueMed or o!(ened for
sale(Sce 7Mq Bus=and Professions Code:The Contratlors License Law
$ does not apply to an owner of property who builds or improves thereon,and OCCGROUP RFS UNITS
whodomsuchworkhlm Ymthmughhbownemploy e,providedthatsuch
Impmvemew art not Intended orof(ered!orectic.IL however,the bulldinB or TOTAL:
Improvement beold withinoneyearofoomple ine,tkavner-bullderwlll have -
theburdenofpmdngthathedidnotbuildorimprove for purpose otsale.). QTY. PLUMBING PERMIT FEE
LJ L as avnwm
er of the property,am ettively nvactlng with licensed N-OOD?ONE APN
mnvactom to construct the Project(Sm 7014,0&ulness and Professions Cade: PERMIT ISSUANCE
The ConAmdoes Llcense Lw don not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EN
Wilda or Improve therron, and who contnm for such ptnjects with a
cWtIactor(e)Ikanaed pumnant to the Cormutcr'a Lioe.Law. BACK FLOWI'ROT'ECT.DEVICE ' FEE SUMMARY
LJ I am exempt under Sec B k P C for this renin
Owns - Date DRAINFTDOK RODE,AA,GOND. SANITARY Y_ N_.
S RE
WOR IGNAN COMPENSATION DECLARATION RFGFL'T Y
❑1 hereby affirm that I have a certificate of consent to self
-Insure,ora FOCIl1RES PER TRAP "AdOOL TAX Y_ N_
certiRcate of Worken Compersationlnsunnce as certified copy thereof LSre. RECF]PI'Y
380,Lab C.) GAS EA.SYSTEM-1 INCA OUTLET'S PARK FTE Y_ N
POICom Y GAS EA.SYSITMOVER4(EA) RECDI'TY
y BUILDING DIVISION FT.ES
Certlflei copy b filed
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertNed copy b filed with the city Inspection dlWtlon.
CERTIFICATE OF U( PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.3TOFT Date Recd t#
(Title section need not he completed I the permit b(mons hundred dolls.
($100)rt l®3 ENERGY FEE Y N
Icertlfy flu"tithe perforeunceof the work brwMchtw pesNtbbsuN, WATER HEATER W/VEM/¢FGTR
I.hall not empby any penin N any runner o a.to become subject to the WATER SYSTEM/TREATING
wcukers'Compensatb .nLawof California.Date PAID
APP llcant
Z O NOTICE E TO APPLICANT-. making this Ccrtllcate of Exemption,you � NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
should bemme.ub)ect to the workers Compensation pruvbkans of the Labor TOTAL:
W~ !A Cade,younuatlonhwnhmmplywllhauchpmvbbvorNbpemJ allbe BUILDING a
y deemed revoked.
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE +
I hereby.form that there b s conutructint kedieg ager cy for the perform ELECTRIC FEE
Z anceofthcworkfor whkA lhb pennR btwM bee 3097,Civ.C.) TOTAL
U O dens Name PLUMBING FEE (W
LL h Lendre.Addmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ir AUythell wv Atwappb UonaMtlstethdtheabwe nfo nWlo
b cone,!.l agree to comply with all city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID:
} N relating to bulldingco and hereby authottre rtprnrntativu a(thb
F U) chytoe the ntbvd property for inspection purposes. ALTERORADDTOMEZH_
,In�`"°'I an a keep h.r,rdea the cityof Cupertino Date Recd t#
alvt U g sant upense w,hh.yh, w.ya a AIR HANDLING UNIT(TO 10,000CFK, SUBTOTAL:
ages sal o/the granting ortw C. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCIIONTAX
i
F&Tu
reotA ant/Contractor to EKHAUSTHOOD(W/DUA:D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS UISCIASURf
Will the applicant orfature building occupant More or handle havrdoua HEATING UNIT(TO I0a000 BTUs Date RCCCi t# -
material asdeftnedbythe CupertlwMunicipal Code,Clupur 9.1 Z,and the ' �D
Ileahhand Safety a Ion 75531(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
E4E Y e No
1111 the epplkM !ulnareebuilding oavpantus equipment ardcvkn VENTILATION PAN(SINGLE IffSID) ISSUANCE DATE
which eMt Iuvrdov air contaMvM.ae delrcd by the Bny Arta Alr
Q.,thty hLvgement�igrp7 BOILER-NMP QHP OR 100,000 BTU) PAM
Yee aaaTdrjl'No LA[{�.
I have read the b.3* erlal, in, under Chapter 6.95 of 110II,ER-COMP(OVFIt1W,000BM TA yyyy
TheC.Ilforn La H'ahh felyC e,Sections 75505,2"M.ed25534.1 SGr e� �Q9Q
um tlf build wtcv rmntlylut er. enant,thetltbmy NEW RESIDENTIAL MECH. SQTT. 1�5sa 4
nslbll a pant d the equiremerta which at be met
f Pat
ort w ry- all Of
Ownerorout ud agent Dale ISSUEDBY:
OTAL
OFFICE COPY