20284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Id7.tifla0on. PERMIT NO.
BtH1ing_Addmss:V 4ap a- - k239-o _ 20284
Uwn.r.Name: Phone: APPLICATION SUBMI I I AL DA IL
10
,`/A- /"1 7'7`(0--215-tl CITY OF CUPERTINO-BUILDING DIVISION
confect rawme: .p` APPLICATION I PERMIT 15 3 D eC D
W BU LDINGELECTR CALPLUMBINGMFCHAMCAl CATEGORY CON ROL
LI N
.:chltect/Engine'.
' QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add / VM MITISSUANCE P•p7 ry �.
LICENSED CONTRACTOR'S DECLARATION
I
hereby affirm that l am licensed under provbiona cf Chapter9(mmmen APPLIANCES-RESIDENTIAL POB DESCRIPTION
with Section 7000)of Division ofthe Bushes and Professions Code,and my
license 'in
fol rce and effect ''II PANELS
LlcenseC LIC.N '-i--� 21,1, c y
Date Contractor El e� /vl -e L�
ARCHITECT'S DECLARATION 301-1000 AMPS l
9OC I understand my playsWRbe used as public rccdrde. OVERIaUAMPS SQ.FT.FLOOR AREA y/SQ,FT.
E Z(j Licensed Profemlovl SIGNS ELSCTWCA
,6 bkluOWNER-BUILDER DECLARATION
P I..�3 l hereby affirm that lam exempt from the Contractor'. se LicenLaw for the gpECCBiCUI PSC
oo followingreason.(Section7aIS,Business and Professions Code:Any city or
OZi-tOi TEMP.M OR LE IN
p� coYstm= priortoits emNce,avrquimstheapmvgdemsu&,'repair \
�see .a any atrucNre tatemelts that
he is licers d Pursuant t the Provisions,
of t e POWER CES
rG � file a signed statement that M b Ilcensed pursuant to the provisions of the
3 O Contasam.Llcc—Lw(Chapter 9(commencing with Settlors 7000)of Divi- SWIMMI POOL EL C
iii---.
-ion 3 ofthe Buslnessand Profesema Code)orNat he is exemptthere(rom and VALUATION
y.' the basis for the alleged exemption. Any violation of Section 7031,5 by any
65 appbcaruforape'mitsubiM theappllcantioadvllpevltyofnm=m(han UTLE TC
.R five hundred dollars(5500).
I as owner of the ro D LEC7R .FT. STORIES TYPE CONSTRUCTION
�n p o the ork,a or employees r theirsole
t compevaHo 11--i ne,and Pmddelmu,Code:Thee is of intended License Lanv
5 O sale(Sec aptly to an�ow end f property
Code:The C Improves thus law
doe not apply torn owner ofproperty whonempWilds or Improves thatand OCC.GROUP RFS.UMTS
who doeasuch
rot.amwork rInthimself nded roughhis dor Is.If howev,the Wild
log or such 1
Improvementsarecotintended r.dWearofrempletile.ILhower-I diders Wingor TOTAL:
Improvement lasold within one ycuo(compl¢tlon,the owner-bullderwill have
t rdenof provingthat he did not build or improve forpurpomofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE A]'N
Lj L as owner of the property,am exchuively contracting with licensed PERMIT ISSUANCE
contractors to construed the project(Sec,7044,Business and Professions Code:
The Contractor's License law don not apply to an owner of property who ALTER-DRAIN AVENT-WATER(FA)
builds or ,Improve roci
thereon,and who ntrae for such pwincts with a
ogptfa Cods)Bernard punuant to the Contradors License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
Ll I am exempt under Sec. B k P C for this recon
.� Owner OUTSIDEFEES
DRAINS FLOOR,ROOF, SANITARY Y N—
Dae RECEIPT N
WORKMAN COMP INSATION DECLARATION IVHVRF_S PER TRAP SCHOOLTAK Y N
❑I hereby affirm that I have o Insurance
of consent to copy thereof
or a RECEIPT N
certRlateofWorken'Compensatlonlnsurance ora certHied copythereof(Sec. GAS EA.SYSTEM-1 ING40
- 3800,fab C.) /�� ^� (� q PARK FEE Y_ N_
Policy N�OZA�I•f�N -- .L�A3 /;!;::,��
Com any J __ 1 -1 GAS EA.SYSTEM-OVER4(FA gU1L)NG n1VI51oN FEES
[�CertlBed copy b h reby th the ed.city CREASE/INDUSTRL W INTERCEPTOR PLANCHECK FEE
Certified ropy b filed�.dlh the tlty Inspection divblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTT STORM EA 200Ff Date Recel t#
Rhb section need not be completed If the permit b(Drone hundred dollars
(5100)orlessJ WATTRHFA W/VENT/m TR ENERGY FEE Y N '
I certify that In the performance of emanner an n to b this penult is lasted,
1 shall not employanypeaws in any mannermeto become subject to the WATER STEM/TREATING
Workers Compensation Tawe o(Glifomia.Date PAID '
O Z Applicant Date Reset t#
Z O NOTICE TO APPLICANT:If,.fter making t his Certlflate of Exemption,you NEW DFNIIAL FILMS. 50}T.
should become subject to the Workers''Compmuat ion provisions of the Labor TOTAL:
04 Code,you must forthwith comply with such pdwinlov or this permit shall be
deemed revoked. BUILDING FEE
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyafflrmthat there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE (�
once of the work!,'which this permit is lsmed(Sec.3097,Civ.C.)
U O lander'.Name PLUMBING FEE
iL F Lender's Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 3m V
O W 1 certlfythat l have read thbapplicatlonand datelhat theaboveI formation �t'A
IL
Is correct.I agree to complywllh all cityand county ordinances and pale laws / PERMTTI.SSUANCE Aa 10Z FEES PAID:
} N relating to building conshuctlon,end hereby authorize representalivn of fhb
I" Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. DRIB RCCeI f#
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date
against liabilities,Judgments,coa.and expenses which may In anywayacvue AIRHANDONGUNIT(MI0,f00CFM)AISUBTOTAL:
agaWteald CLLWnconaaqu¢nes of the granting offhb permit ��
�_ �� R HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigvmreof ppBant/Contactor —1 Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfummbullding occupant storeor handle hazardous HEATING UNIT(TO 100,000 BTU) DRIB RCcel f#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
[1 Y. V]No -
Th'ill the applicant or town,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAN DATE
which emit hazardous air contadranbas defined by the Bay Area Air 4 u�
Quality Management District? Z BOILER-COMP(311P OR 100,000 BTU)
Ye ❑❑No pt u 199Q
have read lheh &Solet materials Irerrenb5533 an 2 car.1 of BOILER COMP(OVER 103,000 BTU) 1c1N1 3
the Californiaandthealth hSafety Code, of carr 25505,ve a tsad35534.I
understand that lithe natty building poet ofterecti haves tenantthat it busy NEW RESIDENTIAL MECH. SQ.Ff.
responspd.,
cenotify the occupantoftherequlrcmenls which at be met t?;t of�up"U1U
prior to bsuanco daCertlBate,fOavpancy. -;t Y
Owners authorized agent DateTOTAL: O• ISSUEDBY: Nt. V
OFFICE COPY