20965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building AddreB;ildin Project Identification " PERMIT NO.
_ - re lk4- 20965
rmrs n J �� ane: Tr`
CITY OF CUPERTINO-BUILDING DIVISION
c° aact "e Lic'No: APPLICATION /PERMIT L
' ' G CC CATEGORY CONTROL N Q
A tent/Fa near BUILDINGELFiCTRICALPLIIMOINGMFLHAMCAL /f�/
pt Lle No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. NS 16w :E PERMITISSUANCE ® I�/�
LICENSED CONTRACTOR'S DECLARATION I� L14J
I omby affirm that l am licensed under provbslonsof Chapter9(commenc APPLIANCES RESIDENTIAL JOB DESCRIPTION
ingwith Senion7000)of DiWM..3oftheBusimssand ProfeW.,Code,and my �j Kyr` A(_--epVN
ho se i in full f and affect. PANELS
License Ckm_ LIc.M
DateGter P014000AMPS
ARCHITECTS DECLARATION
0Z0 Iundentand my plans shall be used upublic records OVER IlDO AMPS - EQ.Ff.FLOOR AREA f/SQ.FT.
Licensed Professional SIGNS ELECTRICAL 4 1 e� /)f
"Z OWNER-BUILDER DECLARATION gpECGLCII4CUIT/MIST D A.1ll
1herebyaflrm that l am exempt from the Contractor's License Law for the
Z following reason.(Ssctlon 7031.5,Business and Profession,Code:Any city or '
q �
F county which require,a Pedro to construct,alter,improve,demolish,or rep, TEMP.MET(RORPOL IVST.
any structure prior to Its issuance,also requires the appRornt for such permit to
Ofile a signed statement that he k licensed pursuant to the provisions of the POWER DEVICES
ud� C mractor'sLicenB Law(Chapter9(mmmencingwithSection7000)ofDielNY-
3 sion3 ofthe Business and ProfessitiroCode)orthat he kexempt therefromand SWIMMING NOL Q VALUATION
y.'S the haW for the alleged exemption. Any violation of Section 70315 by any _ —I D//fl w
QOM applicant for a permit subjects the applicant to a civil penalty of not norethan OUTL SWIICHE- "'
IE]1,a,ve rcwnerdollars thepr. NEWR ALEL STORIES TYPE CONSTRUCTION
❑I,saownerof theproperty,or my employees is with wages as their sole
compensation,7K will do Business
usiness and Prondlhes Code:The
Wended o icame d for
Law
O sok(Sec.7044,Buslrwasand Profenlons Code:The ConOactofs License law
�53 does not apply to en owner of property,who builds or improves thereon,and
EEE who doessuch work himself orthrough Nsawn employees,provided that such OCC.GROIIIP RES,UNITS
Improvements are net Intended oroffered forsale.If,however,thebulldkg or TALo `
improvement ksold within oneyearofcomplatlon,theawneobu0derw111hove ,
t"Iden of p.A.Sthat he did nM build orimprove for purposeofule.). QTY, PL FLOOD FERMI FEE Flo wNE APN
L j 4 as owcar of the property,am exclusively contracting with licensed
contractors to construct the potted ISM 7014,Business and Profession Code: PERMIT ISSUANCE elate
The Contractor's License law don nm apply to an owner of property who ALTER-DRAIN&VENT-WATER @NN '
builds or Improves thereon,and who contracts for such projects with a FEE SUMMARY
cgRUactor(s)licensed pursuant to the Contracts/.License Law. BACK FLOW PROTECT.DEVICE I am exempt under Sec. B&P C for this mason OuTSILEFFITs
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Date RECEIPT N
WORKMAN COMPENSATION ON DECWRAT4ON FLCTURES PER TRAP SCHOOL TAX Y_ N—
certificate
hereby affirm that 1 have• Insurance
of consent to opytheure,ora RECEIPT N
380,Lab o(Worken'Compensatlanlnsurance oracertified mpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS 2 (� PARK FEE Y N
3600,Isis CJ
Policy p ' - RECEIPT 4
any CAEA,SYST'PM-OVER4(EA) BUILDING DIVISION FE ES
EGmCS edified copy k hereby thcity inspection dlvl0on.
e
❑Certified copykllkd with the city GREASE/INDUSI'RL WASTE INTERCEPTOR PLANCHECK FEE
,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE'A'SE TRAP _ PAID aT/��.��//b5'
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date ReCei t# ,e4
Ehlaeectlon need nh completed If NNe permit 0 forone hundred dollars
(f10fimless.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
I ll net employ
any Orson In an manner
so as to become
permB is blued, (-.4U
I shall not employ any person in any manner at u to become mbject is the WATER SYSTEM/TREATING
Workcri Campenution lawn o(GWomk.Data PAID
NEW RESIDENITAL PLMB._SQbT.
Applicant
Z0 shoulNOTICEcome MPLICttothe aNeres'C..hOxtion paleo(FiempteLabo Date TA t#
Code you=at forthwith
co Workers'Compens islom o this peof the Labor TOTAL:
LU N Cade,you=at forthwllh comply with such prov4ions orlFO permit shall ha �.
j Beamed revalued. BUILDING
LU
p CONSTRUCTION LENDING AGENCY SEISMIC FEE 4
Z Iharebyaflrmthat there k a mnstrunlon lending agency for the perform- TOTAL ELECTRIC FEE D
D ao..fth.workfar which thin permit fit sasued(Sec.3097,CIv.C.)
O O Landers N. �� PLUMBINGFEE
LL F Lendce.AddreB QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 1755
OW Icertifythall have read lMsappRcetlon and Gatethattheabovelnf°moat.
6 bonded.l agreetocomplywith allcityand countyordinancesand statelawsPFRMUISSUANCE 11(Z FEES PAI D:
} relating to building construction,and hereby authorise representatives of this
F city to enter upon the above-memloned property for inspection purposes. ALTERORADDTOMECH.
Z
_ (We)agree to save,Inst mNfy n d keep harmless the City of Cupertino - Date Recel t#
a g.nstllabllit s,juit mems rad expenxs whit mayinanywayacaue AIR HANDLING UNIT CIO 10,0DO CFM) SUBTOTAL'
,gat stsaid 1 s u it grantingd permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
1 re Applin an o actor - Date 19(HAUST}iWD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WI the applicantwfuture building ocmpant aforeor handle hazardous HEATING UMT(TO 100,0000N) ((� Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
firellh and Safety Cade Ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) AL:
❑Yes N
WIII/M1°opplicatoo u mbuilding ompanlum equipment or devices VENTILATION PAN(SINGLE RESID) ISSUA C'
which emil tea rdom Ir mnnrriants as defined by the Bay Area Air cCU
� Q�iallty Mavgcrrct Id BOILER-COMPOMPOR100,0(ABTN J`1 `` 1o9O
4 Yn V 7
Q* read the Foss ousmmekalarequimmnlsunderChapter6.95°f BOILER-COMP(OVER 100,000 BTU) �
the California Health fety Cede,SMIons 25505,2SS33 and 25534.1 //11 y �I•VY
understand that lfthe lading does not currently h a tenant,that It is my NEW RESIDENTIAL MEIN. SQ,FT Q Mpi4l '
rnpoulbillty nullfy the pa of the requ rat which mrsl bs met PP''�B��tEf�
prior toW cc G (I Ocovpanry.
. _ /
Ow o utho0reda Data TOTAL: saaee{/i�,� ISSUEDB� Yom—
,
OFFICE COPY