20650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Addm,,: 20650.
a F�Na�2 r-r.
wnere one:
Ca —(9Q CITY OF CUPERTINO-BUILDING DIVISION r� L^ O
Ls.N. APPLICATION / PERMIT -3 7
V-- abl T-t`3 d BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROI,goq
t ArchBeC/Engbuer. Lie.No: CJJ
QTY ELECTRIC PERMIT . B BUILDING PERMIT INFO
Address: 11 PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION K V
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPUANCF RESID-VIAL ry(�•�4.JOB D1PSC`RQ'17ON
Ing with Section 7000)of Division 3 offle Businessand ProfesslonsCode,and my PANELS � 1\
licensebinfillf�amddfec' s� � 00.1\ )
Line C LIc.N (� .6..� f� �s,tt�TY
Dale_ — Contra \3 1 \�� v.ay�
TQ"AMPS VA�p V z
ARCHITECPSDECLARAT N 701-10DOAMP5
pp?0c Zp I understandmy plane shallbe used as public records. OVER I=AMPS SQ.FT.FLOOR ARETA� S/SQ.FT.
Fj Licensed Professional SIGNS ELECTRIC` L �l0\V �O yf sqZ
<�Q OWNER-BUILDER DECLARATION SPFCIALCIRCUIT/MISC V✓
Ihcrebyaf .that lam exempt from the Cmacadm',License Law for the
7.9 �p following mason.(Seelon 7031.5,Business and Profession,Code:Any city or TEMP METER ORPOLEI
FLf"ul county which requbva permit tocumruct,alter,improve,demoll,h,or repair
q'Y�YS� anystrvctvrc pderto its issuance,also requienthe applicant for such permit to POWERDE—ES
E K V file a signed statement that he Is licensed pursuant to the provbimss of the asp �w -160
�swG Contractor's License Law(Chapter 9(commencingwith Section 7000)ofDivi- SWIMMING POOL ELECTRIC VAL [i'6)R
O skm3ofthe Business and Professlom Code)orthat he b exemptilumfromand
0 S^5 the barb for the alleged exemption. Any violation of Section 70315 by any UTLE7SSWI7.CI ES,HXTURES
�lyo� applicant for a permitsubjedsthe applicant to a civil penaltyof not rrorc than
cc five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
C7� n�I,as owner of the property,or he employes with wages r thele sole �` I
1,a,oon,,ll odoth.oprk,and rty,or ymcmrcbnest wtntended hwageor offered sole
p sale(Sec.7034,Business and Professions Code:The Contradoes License Law
�S$ does not apply to an owner of property who Wilde or improves thereon,and pCG.GROIR' ;� I� R
c. whodosssuchworkhim iforthmghhbownemployees,providedthatmch 1 �Ji �� I'11J11 B
Improvements amnot intended oroffered forsale.ILhowevegthebuildingor T �✓
improvement band withinoneyearofcompIdWm,theowner-bullderwill have
thp*rden ofproving that he did not build or improve for purpose o(sakJ. QTY, PLUMBING PERMIT FEE A-�LOpp A
W.
Lf 4 as owner of the property,am exclusively contracting with Ikenxd PERMIT ISSUANCE ��
contractors to mretruct the project(Sec.7064,Business and Profession Code: — -
The Cont rider's License law docs not apply to an owner of property who
Wild.or Improves thereon,and who contracts for such p(ojects with a ALTER-DRAIN&VENT-WATER(EN
cWil[ador(a)Icensed pursuant to the Contractor'.License Law. FEE SUMMARY
01 am exempt under Sec B &P C for this mason BACKFLOW PROTECT.DEVICE.
DRAINS G,FLOOR.ROOF,AREA,COND. SANITARY Y_ N_
Owner - Date RECEIPT#
WORKMAN COMPENSATION DECLARATION 711
PER TRAP �+ SCI100L TAX Y_ N_
711 hereby affirm that 1 have a certificate of consent m eel(-Inmrc,ora RECEIPT N
certificate of Workers'CoceperaatlonInsurance or a certified copy thereof(Sec. 1 GAS G.SYSTEM-11NC40U'ILEfS �. PARK FEE Y_ N_
3800,Lab C.) 1 RECEIPT N
Policy N GAS G.SYSTEM-OVER 4(FA)
C
EfCerty
BNLDINC DIVISION FENS
om aniOed ropy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCcr iOed copy b(tied with the city Inspection division. ..
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE THAI' PAID 1�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.IOOFT Date Reed t# a
(Thbsedlon need net be completed if the permit is for one dollars —
dd dolla
($100)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
1 minify that In the performance of the work for which this permit Is issued,
I shall not employ any person in any manner an as to become subject to the WATERSYSTFM/TREATING
Workers Compensation Law,of CaBforma. Date PAID-
0
AID0 Z Applicant NEW RESIDENTIAL PCMB. SQFr. Date Remi t# 00
Z NOTICE TO APPLICANT:If,after making this Certificate of lsemptlon,you
0 should become subject to the Workers'Compersatlon provbiom of the Labor TOTAL: I
t— N Code,you most fort hwith comply with such provisions or this permit shall be
W j deemed revoked. B 1 G - _
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d G l hereby affirm that them is;a corutmedon lendlegagency,forthe perform T ELECTRIC FEE
Z arm of the work for which this permit b issued(Sec.3097,Civ.C.)
02 Lce&e.N. PLUMBING FEE
LL H Lender,Adden, Q'T'Y. MECHANICAL PERMIT FEE MECH, MCN L FEE �—
U 1 certifythat l have mad this application and statethatthe above Information
0 is correct.l agree to comply with all city and county ordinances and mate laws L PFRMTTISSUANCE FEES PAID:
} f1 relating to building cormlrudion,and Wreby authorize mprese t tives ofthb
r Z city to enter upon the above-mentioned property for Wpectionpurpoees. ALTFRORADDIOMECH. Date Reeel t#
V _ (We)agree to save,indemnify and keep harryess the City of Cu peMno AIR HA I1NH'(TO IO,000 CFM)
agamull.bNtbp menti,etaan'e;pennxs�lM,,b may In anywayamue SUBTOTAL:
agai dC' I nuqu eo h ❑ of this pc it. CONSTRUCTION TAX
g (/((Qa�� AIR HANDLING UMT(OVFR IO,ODOCFM) -
namrcof Applicant/Contractor Uate`r EKHAUSTFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilltheappBcaniorfuturebuildingocmpant,mreorlundleh.,dou, FfEATING UNIT(TO 100,000 BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Ssfcty Cade Section 25537(.)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yn M No
Willtheapplicam orfuturcbuildingecmpant u,eequipm etordevices VENTILATION FAN(SINGLE RESID) ISSU!4'CE.DATE
which emit lutardous air conta mbunts as defined by the Bay Arca Air
Quality Marugcment DusMct7 BOILER-COMP pII'DR 1 W,IXq BTU)
Y. ❑❑No (SPR NjO
4haif read the
ealth&rcafety C de,Se requirements und and 2S5r6.95 of BOILER-COMP(OVERI00,000 BTU) �P i1 ]flog
the Gland t It title
&Safety Coda Sections ally h ve.l and 7:534.1 1s7s7[
understand that lithe Wlldingdces notmmently haveatenanL that ltbmy NEW RESIDENTIAL MTECH. SQ.FT. /s -
responsibilitytonotlfy the occupant of the requirements which must be met CI�Y Wf `ul'Cli I Ii u n
prior to Issuance cis Certificate of Occupancy.
Ownermauthorizedagent Date TO ISSUEDB $, .
OFFICE COPY