20489 APPLICANT TO.FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification PERhfITNO.
Building Address: 1 AA _ 20489
rmlee
-55-T711 CITY OFCUPERTINO-BUILDING DIVISION
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Contndor,Name: - /� L3c.No: APPLICATION / PERMIT 3 —(
• IAF , Frl"o Q,yl l'M N 52 BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROLp
Architect/Ggineer. Llc.No:
_-- BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address: -- PERMITISSUANCE '�_O(1, _
LICENSED CONTRACTOR'S DECLARATION
I hereby thSedion7OOthat tam Bcenseftheunder Buimmandsaffesem.r9(comunenc APPDANCESRESIDENTAL JOB DESCRII'170N
Iconari in full
70fA)of Divfect. o(the Buslnesand Pro(eadona Code,and my -
IlcenseislnfuB! end effect. PANELS
License Class=Lk,0 521101 /,/�� /,//�
Date S-}!—ft Contndor_
ARCHITECPS DECLARATION 201-1000 AMPS V
Zr. I understand my plansshaB ro
be used as Public rerds. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ,FF.
AFi Licensed Professional SIGNS ELECTRICAL
�`4of OWNER-BUILDER DECLARATION SPFGULCIXCUIT/M1SC -
Zt., IherebyafBrmthatlamexempt from the Conlrador's License Lw forth,
oo following rescan.(;e tfi.70315,Bualnes and Prefesion.Code:Ancity.,
OZF� oTEMP.METER ORPOLE 1NSf.
countycture requlma issuanmcooraquialter, aprovgdertnuor ch,orrepair „
anystructure priarto statement
that
he is also sed pursuant
t the provisions
of t e ,
rN1 file a signed rtatemeLa that he Is Bcensed pursuant to the pro 7000) o! the POWER DEVICES
Oaf
Contractor's Business
Law(Chapter feento9(mmmendat he Is xempnherefom and
&O�nS tlon3ofthe Bus3neeeand PMeslonCode)orlhat helaemmpttherefromand SWIMMING IA70L ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by anyU 0 D 6
M> applicant fora permit subjects theappllcant to a civil penalty of net more than OITIT.E?'SSWITCHESFrxET.ERFS U
five hundred dollars f. NEW RESIDENTIAL ELFLTR
❑I,as owner of the property,or my employee,with wages as their sole SQFr. STORIES; TYPE CONSTRUCTION
z compensation,wllldothe work andthestiucture Is not intended or offered for
Sf OO sa1e(Sec.70KBue1nnsand Professions Code:The Contactors License law
R don cm.pply toan owner olpropeny who Wilds orimprovesthereon,and - OCC.GROUP RFS,UNITS
0. whodoeaeuchwork hlmml(orthrough hlaownemployees,provided that such
Improvements arc not Intended oroffered for sale.I(,however,thebuildingor TOTAL: ,00 -
Improvement 3ssold within mneyeaiofcompidion,the owner-builderwlll have
ttrl,,,Iturden of proving that he did not Wlldorlmproveforpurposeofsic.). QTY, PLUMBING PERMIT FEE F DZONE APN
LJ[as owner of the property,am exclusively contracting with licensed PERMRISSUANCE
mntracim to construct the project(Sec.7044,Business and Trifles am Code: IN
The Contndor'.Livens Lw does,not apply to an owner a property who
builds or Improves thereon,and who contracts for such ptojecte with a ALTQLDRA3Nk VENT-WATER(EN O
cg0.t�aa r(.)Ikensed Pursuant to the Contndor'.License Law. — FEE SUMMARY
,am exempt under Sec B h P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FT.00R ROOF,AREA,COND. SANITARY Y N
Owner Date RFCFEff
WORKMAN COMPENSATION DECLARATION SCHOOL 7A% Y N
❑I hereby affirm that I have a certificate of consent to Neat-Insure,ora FO(TlJRES PER TRAP +� RECEIPT p
Owneratc o(Workers'Compensallonlnsuance ora certl(led copy (Sec. CAS EA.SYSTEM-1 WC.4 OUTLETS PARK FEE Y N
3800,Lab C.)
Policy# GAS EA.SYSTEM-OVER 4(FA) RFJ=N
Com any- - BUILDING DIVISION FEES
❑pCertlfled copy 4 hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE 6
❑Certified copy Is Filed with the city inspection division. J^
CERTIFICATE OF EXIMPI'ION FROM WORKERS, GRIIBTRAP I' PAID
COMPENSATION INSURANCE SEWER•SANTTARYSIORM EA MOPE Date Revel t#
Rhie section need not be complcted lithe permit Is(Drone hundred dollars
(5100)ar les.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mrdly that In the performance of the work for which this permit is Issued,
I shall not employyany person In any manner ro s to bens bjed to the WATER SYSIFM/TREATING -
Workers croon y oLaw Ilfo:w.Date_$=}(� PAID '
ZZ Applicant_A�-/`�Q NEW RESIDENTIAI.PLMB. :[]Ff. Date ReCel t#
O NOTICET'O PLICANT:If,after nuking this Certificate of Exemption,you
Fshould berorte subject to the Workers'CompewtIon provisions of the Labor - TOTAL:
N Code,you mu.1forthwilhcomplywithsuchprovisionsorthispermitshallbe BUILDING 11700
W 0 deemed revoked.
aCONSTRUCTION LENDING AGE'N'CY SEISMIC FEE O
I hereby affirm that there las a constmdion lending agency for the perform- TOTAL: ELECTRIC FEE
Z once of the work for which thb permit blaaed(Sec.3097,Civ.CJ e.�
(� O Lender'.Name - PLUMBING FEE
LL I— Lender'.Address QTY. , MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1xAfythat l have read this application and statethattheabovein(omvtlon16
1 Ismrmd.Iagreeto comply with all city and countyoniinaom and state laws PFRk0.rr lssvANCE -D0 FEES PAID:
relating to bullding mvtrudion,and hereby authorize representatives of this ,
FZ city to enter upon the above-nmntked property for Inspection purposes. ALTER ORADDTO MECH. Date ,Revel 1#
(We)agree to save,Indemnify and keep harmless the City of Cupertino P
agaWtllabNtin,pdgments,cod.and expenses which may In anyyayattxue NR HANDLING UNIT CTO 10,000 CIM) SUBTOTAL:
against mid City In consequence of the granting of this permit.
Z&/Zo -GOL-� 5�3�- f0 AIR HANDLING UNIT rovtR to,lm cr•M) - CONSTRUCTION TAX
- Signature of Applicant/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future bulldingoccupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chaptcr9.IZ and the Date _ Recei t#
Health and Safety Code Section 255324)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: f.aCA-
Yn dji trNo
❑ t `
Wllltheapplicant o building occupant use equlpnim ordevices VFNfILATION FAN(SINGLE RESID) ISSUANCEDATE -
whichemlthazardousaircontaminantsasde0nedbythe9zyAreaAlr - a ay
Yn
Quality BOILER-COMP(3HB'OR10Q0a)BTU) t AID
qTSI No
have read thefiaz ematedals rcquircmnnlsunderChapler6.95 of BORER-COMP(OVER lO0,0006N) r;�(yY311 �rte,
'" .
tfie Califomla Health h Safely Code,Sections 25505,25S33and 25534. I - ,
understand that if the building don not currently have a tenant,that it Is my NEWRIESIDFN73ALME01. SQ.PT
responsibility to notify the occupant of the requirements which must be met -,
Prior to Issuance of a Certificate of Occupy ncy. , 'City of cuperfI11Q
Ow�
Oor lhoriud,genant Date - � � VIVI�x
' -TOTAL: 6-SD ISSUEDB
OFFICE COPY
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- ---- This set Gt-pians=nc� peNfica8 ns
-- - I _— t__ be kept on the lob at al times kdd it is I
j i -I (awfuTp mage aqy creages or aM.-� s ---
i t on same wnh�cut 'w� ctat �m§sion fr �� ' I —
! he bwding D=pi Cty of dupe tino. 9� 3Io i ! i (3LDG INSPECTION DEPA'RTM'
rZr,%gfty the stain in�`cf h s -
P p-En <r a �pacihCatiorf s i i i Qi1f DE DUPERiINQ
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HALL NOT de he d t p and or-to be an
� ° INproval of the viulahn of ,any I provisions I
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