20678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO..
Building Address: —211 :5 I, r 20678 0 6 7 8
J6 5AVIA�� C1112Y', Dr
G
a - - Phone;4
i �O hagW.SOr1 f .(' 3�Q�j V4 CITY OF CUPERTINO-BUILDING DIVISION (� �
c°"tra .r'aName: Lic.No: APPLICATION 1 PERMIT `
BUILDINGELECTMCALPLUMBINGMECHANICAL CATEGORY CONTROL N
Architm/Engineer. Lie.No:
-.. Q QTY ELECTRIC PERMIT FEE
BUMPING PERMIT INFO
Addrem:t r0CV 0 rJ PERMITISSUANCE - ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that l are llcmmd u Mer provisions of Cha pier 9(coc- APPLIANCES-RESIDENTIAL JOB DESCRB'I[ON
ingwlth Se i.. 000)ofMMsi.n3ofthe Bu.J rand Lhofesslon.C-.de,and my
I icense is In hi fora nddf .� O PANELS
License tae bye A LIcN� 00,
Oats .Contnct.rt7h 1^�
CHITECFS DECLARATION 201-i 000 AMI"' XreOZpI understand my pia.shall be used as public meads. OVER IOOO AMPSSQ.FT,FLOOR AR S/SQ.FT.
b(1 Licensed Profemio.l SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFCIALCRtCUIT/MLSC^ZI.^ ;� [hereby afRrm that l amexempt from the Contractor's License Law for thefollewing reason.(Rection 70115,Business and Professions Code,Any city orcounty which requires a perndt to w.truM alter,Improve,demolish,or repair TEMP.METM OR POLE INSAA
1anystm=mprlortallsL anteaLtorcquimatheappliontforsuchpermltto IKIWER DEV[file a signed statement that he is licensed pursuant to the provlslo.of theContractor's License Law(Chapter9(nenme.eingwithSectio,7000).lDIv1-
si.n3oftheBud msandProlemio.Code)orthathebexemptthemfmmand SWIMMING L ELUATION
the basis for the alleged exemption. Any violation.f Section 70315 by any OUn,ETS$WITG I U y J-
Q5 applicant fora permit subjects the applicant to a civil penalty of net more than ` v
five hundred dollars he pr. NEW RESIDENTIAL TR SQ.FT, STORIES TYPECONSTRUCTION
�n ❑e as owner ll the property,or my employees with wages r their sole
comp(Sec,
704,will dothe work and th..t ode:Th not Contract.?.
intended or offered for
O doe(Sec.7ply to an owner of property
Code The or improves
ves Licecoe Law
�$ d°esnot applytoan.wnerofpmpertywho Wilda°yees,povided that such
- - OCC.CROUI' RIS.UNITS
who pr.v, e n a am k t Intended
.rough hbowne.If,however
oeev provided r
Imprevementsarc not Intended oro!lcrcd for sale.thrcw ,.WIldr,lldingve TOTAL: -
improvem.ntiswldwltM1ln aneyear.(<ompldlon,th.ewnenbullderwlll have
tl);kurden°l proving that he did not build or Improve for purpose pial..). QTY, . PLUMBING PERMIT FEE : FLOOD ZONE MIN
Lf L as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE -
contractore Ie ronslmR the projed(Sca 7044,Bualnex and Profexlo.Code: - '
The Contrictor's License Law does not apply to an owner of property who ALTER-DRAIN kVENTWATER(FA) _
Wild.or improv°.thereon,and who contracts for each ptoktts with a - FEE-SUMMARY
C, actor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT,DEVICE
LII am exempt under Sec B k P C,for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N�
Owner - Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER,TRAP. SCHOOL TAX Y N
❑I hereby affirm that I have a cerllfl.m of consent to self-Insure,or.a RECEIPT N
certificate of Workers'Compe.itlon Insurance ors certified copylhem.f(Sec.
3800,Lab C.) GAS F.A.RYSTEM-]INC.4 OUTLET'S, PARK FEE Y_ N_
Polity N GAS FA.SYSTEMAVER 4(FA) RECEIPT N
Com any BUILDING DI VISION FE.115
]ti'fCertified copy is bed with the
ed
city - GREASE/INDUSTRL WASTE IN'T'ERCEPTOR PLANCHECK FEE
❑CerlBled copyisfiled with the city Wpettlen division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPPAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FF. Date Recel tH
(Thls.ectlon need nU be completed[(the permlt Vier°.hundred dallarc
(S1 W)or lex.) WATER HEATER w/vENT/ELECTR ENERGY FEE Y N
[Certify lh the pedomunce olthe work f.rwhkhthls permltbissued,
I.hail not e I any rwn In any manners°u to subject to the WATER SYSH7d/11LEATINC • ..
Werken'co nud of GIIlomla. Date PAID
O Z Appilnnt NEWRESIDENTIALPLMB, SOF, Date Recei tN
Z O NOTICETO IC after rnskingthisCartBkate.f Exem)xl.n,you
sM1ruld become wbjm Workan'Compe.atl°n provlslonsafthe Labor TOTAL:
~ N Code you muBUILDING FEE
eni. wit comply with such provisions or this permit shall be '
j deemed revoked.
d G _ CONSTRUCTION mdi.o en nceNer SEISMIC FEE io
I hereby affirtm that there i e conswctlon[cedIng.gency for the pedorrrt ELECTRIC FEE
7 Z Larder'the work for which this permit islssued(Sec.3097,Civ.C3 TOTAL:
V O Lena.r•.Name PLUMBING PGE
U. I— L.endee.Addsom QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W Icertlfythat l have read thisappBoUonand immthattheabove Information
IL
Iscovect.I agree to comply with all cilyand county ordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to building construction,and herebyauthodze representatives of this
)... Z city to enter upon the above-mentWned property for inspection purposes. f ALTER OR ADD'TO MFCH.
(We)agree to save,indemnify and keep harmless the City of Cupertino Date Reeei ted
V against llnbNtln,jadgmenb,mete and.:pecten which nay In anywayamue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against Bald City In consequence.(the granting of this permit, AIR HANDLING UNIT(OVER 10,000CLM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date E)(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant orfnum building occupant store or handle hazardous HEATING UNIT CFO 100,000 BTU) -
materialasdefinedbytheCupertl"°Municipal Code,Chapter 9.12,and the Date Reeei t#
Health and SafetyCede SvdI.r 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yen1r�–,1 N° -
Willtheappunnter/uture building occupant use equipment°rdevims VENTILATION FAN 6INGLE RESID) - ISSUANCE DATE
y� which.Management airrict? ants as defined by the Bay Area Alr
Quality Management DlsWtt7 BOILE&COMP(311POR 100,000 BTU)
'?Yes 1�IN° `9
have No
etymaterials Sections
25505,25533
sundand 255r4.95 of BOILER-COMP(OVER 100,000 BTU)
-
the CallfornWeIealth IfhlkSafetyCode,S .,m2tlyh25.tandt th3tiI �( ) I1
unders ndyto notify the
eocgdant not .require encs tenant, ustb la my NEW AESIDFNTIAL MECH. SQ.FT. J`>�. V ly�y
respo i ily to notify the°ccupant°f the requirements which must be mal
'peio i uanccof Iticateof Occupancy. ^ o ,
Owner. oath. zed gc [ t - D _ ISSUED
TOTAL:
OFFICE COPY