20064 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 20064
.Za S)O µoY ¢Sea Q
rase a ams: one: A A
Sao Nm y CITY OF CUPERTTNO flUILDINC DIVISION 3 _ Z� —q d
L DAIE
c^ntnnf'k '(. l I I un.Nn: APPLICATIONIPERMIT
- 1 lI gi G QC' [O N S I J / 1�Q 7
Architect/En BUILDINGMLCIiAMCAL ELECnUCALnUMBING- CATEGORY CONTROL M
&^eer. Ge No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: )-c 6 D l i
PFRMITISSUANCE �QeI ❑ ❑ ❑
LICENSED that I a CONTRd under eDECLARATION (�
I hereby 1um 7000 l am licensed under Pre
ChapteC Code,
c- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwilh�Seaction 7000)0(Divlslon3oftheeuslneuand ProfeaslonsCode,and my
license is in(u8i{orre and effect. ,1 yea rANF15 I- VN
License ss/�m��f-�—Lie.N ( ct /� B ��V\ F{V4�
Date Contractor D�YQ Zr�S 11
ARCHITECTS DECLARATION 201-1000 A.MIPS
G O Iundersta^d my plans shall be used as public records. OVER1000AMPS SQ. j0ffrA $/SQ.FT.
m d o Licensed Prelfesstmal SIGNS ELECTRICALFIN
�<Z T R
OWNER-e UILDER DECLARATION SPECIAL CIRCUIT/MLSC
L., L Iherebyaffirmfhat l am exempt fromthe Contractors License law for the
O'L�70 county hrequiroaa n7it tocosinessand Professions Code:And or t
following y city TEMP.METFR ORIOLE INST. /W
� '
K��y county which requlresapermitromnstrut,alter,improve,demollsh,orrepalr
anystrucwre prorto its issuance,also requlrestheapplimet for such permit to POWER DEVICES
O 0.S file a signed statement that he is licensed pursuant to the provislom of the
g3 Contractors License Law(Chapter 9(conurencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
t,E, sion3ofthe Busineasand PectessmaCedOmthat hebexempttherefromand VALUATION
Qv�,t 9 the basis for the alleged exemption. Any violation of Section 70315 by any OUfLETSSWITCHESEXTURFS ('� O
E O� applicant for a permit subjects the applicant to a civil penalty a not mare than 36 0 Q r
e five hundred dollars($500. NEW RESIDENTIAL ELECTR FI'.
❑I,as owner of the property, SQ SIO TYPE CONSTRUCTION
p perry,orhe employees r their
or
>,:
compensation CSo.71Buldess and rkandthestrode:Th nontractrIntended o icereredfw
O sale(Sec 7014,Business and Professions Code:The Contractors License Taw
[Pj$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUI' RES.UNITS
GG who dcessuch work himselforthrwgh his own employees,provided that such
Impmvements arc not Intended ororfered forsale.If,however,thebuildleg or TOTAL:
improvement'b sold within one yearafcompletion,the owner-builderw111 have
I"Men of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE }Tqp zDNNE ApN
I,as owner of the property,am exclusively contracting with Ikemed PERMIT ISSUANCE
contractors to construct the project(Sec.7064,Business and Professbru Code:
The Contractors License Law does not apply to an owner of property who
buAE,ppR DRAIN&VENT WATER ffA)
Wilds or Improves thereon,and who contracts for such pRojme,with a
CII[actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason
• Owner Date DRAINS FLOOR ROOF,ARE A,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEPT 4
01 hereby affirm that I have a certificate of consent to self-insure,or a FIXTURES PER TRAPSGTOOLTAX Y N
anifluteof Worken'Compematlonlm nnmorace6it dropythereof(Sec. RECEIPT
3800,Tab CJ GAS F.A.SYSTEM-I INCA OUTLETS PARKFEE Y N
11
oliry tl p 9 s ro F L RECEIPT tl
Com any'PfW/4 jE f GAS EA.SYSfPM-OVER 4(FA) BUILDING DIVISION FEES
ECert fled copy Is filed Mthrthe city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�GaniRed copy V flled'wlth the city inspection division,
CERTIFICATE OF F](bTIPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FF Date ReLCI ted
(This section need nes be complied B the permit la for one hundred dollars
($1 W)orfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]artily that Nthe pursesunceofthework as,as
ch Rhone,stnifis issued,
I shall rs empty any person f any manner n n to become subje t to the WATER SYSTEM/TREATING
Workers Compensation Iowa of�uromla. Dale PAID
O Z Applicant
Z O NOTICE TO APPLICANT.R after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recei tis
should besubject to the Worker'Compensation provldoru of the Labor
P: W benne subject
you must fort hwith comply with such provisions or th W permit shall be TOTAL:
LU > deemed revoked. BUILD NG FEE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE .Z
I hereby affirmthat there Is a construction lending agency for the perform-
Z ance of the work for which this permit is R5e
Issued c.3097,Civ.C.) TOTAL: ELECTRIC FEE
U O Landers Name PLUMBING FEE
IyF Lenders Addres QTY- MECHANICAL PERMIT FEE
O W 1unifythatl have read thisappBcmlona.dsntethattheabovelnformation MECHANICAL FEE
4 umrmt.I agree to comply withaR citya^d county ordinances and state law, PERMUISSUANCE FEES PAID:
} W relating tobullding cormtmctlo^,and hereby authorize representativesofthis
I"' Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
V — (We)agree to save indemnify an d keep harmless the the City of Cu ped Date ReeeiptR
against liabilities,judgments,cestaand expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Wt uld Gly to consequence of the granting of this pemnl
dr �y>,y��n AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Slgnatum of Applicant/ ontramor f ue IXHAUS'r HOOD(w/DucT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappliunt or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defl^edby the Cupeyyyyyylno Mu NClpal Code,Chapter 9.1 2,and the Date Recej ted
He❑alt hand S.fety Cm25532(a)1 HEATING UNIT(OVER 100000 BTU) TOTAL:
Willtheapplimnt orf�ut(ugrebulldingompantuseequipment ordevices VENTILATION FAN(SINGLE RESID) ]S$Ila,-,�J�ADA•FE
which emit hazardou air msnta me as defined by the Bay Area Air r/tIV�
• Q'+ lity Management ri BOILER-COMP(3FN OR 100,000 BTU)
4Yes
hawemad the haza meterialarequlrementsuode,Ch.pter6.95of BOILER-COMP(OVER 100,000 BTU) (.,��n 2 y 1g9U
the Califemia Health&Safety Code,Sections 25505,23533 and 25536.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MEIN. SQ1:F
responsibility to notify the onvpart of the requlretments which at be mrd
pritoyrc issuance Of l,�s1Ceniifl-u'tt o--fOavpanry. �fQ/� City.at CV p
Owner or authorlred agent `Dat
TOTAL: ISSUED BY:_xL k3)Ykv-
OFFICE COPY