20945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
JC3Y6 / Ne aaL- Aix 2094
nems me. ee.: APPLICA PON SUBMITTAL
7612- CITY OF CUPERTINO-BUILDING DIVISION
Contactors Nam: LIc.No: APPLICATION / PERMIT —" '—�
A e to 4 S Ny 4>V1\. Yo'If I I I- BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CAIMGORY CONTROL»
Architect/Eegleser. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: �ooSJ' 2.¢JVrt7+tJ Ate.
C �^ PMWTISSUANCE El1:1LICENSED CONTRACTOR'S DECLARATION
I hembyaffbmthal l am Licensed under provisions of Chapter9(comran APPUANCESRESIDENTIAL JOB DESCRIPTION
Ingwilh Sec lon7000)of DiAsion3 ofthe Businessand ProfesslonsCode,and my
license is in full form and died. PANELS
License Cl.®.m i Lt.» YuYi /� g
Date f-���_Conhador fyn efR �_�-TR�uwrt(fk ar/ IM TO 20DAM
ARCHITECTS DECLARATION 201-IOW AMPS
2 I understand my plare.hall be used as public reminds. OVER IOW AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
ou�(qO
W���uuuu/ Licensed Professional SIGNSELEC7RIC
�6Fa OWNER-BUILDER DECLARATION SPECIALCKCUITNVY
Ihseebyafion that am exempt from the Contractor's License Law for the
following reason.(Section 7011.5,Business and Professions Code:Any city or TEMP.M IN
t' county which requires a permit to coestrun,atter,Improve,demolkh,or repair
q� any structure prior to its Issuance.lw requires the applicant for such permit to WERD
EKVf5 y�a Bk a signed statement that he Is licensed pursuant to the proWslaru of the
6Q 3 m Commome.License Law(Chapter 9(commando,with Sedlon 7000)o(Dlvl- VALUATION
the
.Ion 3ofthe Buslnessand Professions Code)orthat hale ex.mpttherefromand L C
< the basis for the alleged exemption. Any violation c Section 70315 by any O .� FI
t]
applicant fore permdtsubjed. room applicant to a civil penalty of not rre than
five hundred dollen L$5001. SQ,Fr. STORIES TYPECONSTRUCTION
of,as owner of the property,or my employees with wages as their sok RESID L ELFOTR
compemation,will do the work and the structure is ono Intended or offered for
O .a Is&c.7064,Business and Proliced.m Code:The c.mma.e.License Law
aF0...���$2 does not apply to an owner of property who Wilda or improves thereon,and OCGGROUP RFS.UNITS
whodomauchwork himeelforthreugh hisownemployees,provided that such
Improvements are not intended oroffered forsale.It however,thebullding ur TOTAL:
Improvement bold withinoneyearofcomple ion,the owner-bu0derw111 have
0%NMenofpmvingthathedld notWRdorimprove(orpurposeofeale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed
nt.dors to construct the p.*d(Sec.7064,Businessand Prefessimo Code: PERMIT ISSUANCE
The Cors License n e law donet apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wor imp .
builds or Improvthereon, and who contracts for such p(oject.with a FEE SUMMARY
cgplractnexemtunderwnt to the Contractor'.license Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this mownOUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT
WORKMAN COMPENSATION DECLARATION N
SCIY N
QI hereby affirm that I have a certificate of consent to eelf4nmre,or a FIX'IURF.S PER TRAPPa TDOL 7A%
RECEBT»
certificate Worken'Comns
peatloninsurance ora certified copylhereo((Sw.
380(1Lab CJ GAS EA.SYSTEM-1 INC4 OUTLM PARK FEE Y N
35 W,
Policy GA&EA.SYSTEM-OVER 4(EAI DING TN
Com any BUILDING DIVISION FEES
FlCertlftedcapyisherebyfuMe efty GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Cedlfied ropy V(ikd with the dty Inspedlon division. '
CERTIFICATE OF E%ETIPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.XIOFC. DatC RCCCI t#
(Thi..Oion need nd be compleed If the permit Is far one hundred dollars
(5100)orl.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I.dify that In the performance ofthe work forwhich this Permit is issued, —
I shall not employ any person In any manner an.to become subject to the WATER SYSH]rf/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Rcs:ei til
Z NOTICE TO APPLICANT:If,after making this Cedlflcate of Exemption,you
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
N) Code,you rrwatforthwith comply with such provisions orthlspermit shall be B G O�
W 1 deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemhy affirm that there is a construction lending agency forthe pedorm� ELECTRIC FEE
D Z ance of the work(or which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
V O Ie.der'.Name PLUMBING FEE
LL F lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ImdlfythatlhavercadthbappBratlonan Matethattheabovelnfarmatlon
C iscorred.l agmto comply with all city and cauntyordlnancesand statelaws PERMITLSSUANCE FEES PAID:
>. relating tobulldingronstrualon,and hereby authorize representatives ofthls
U) city to enter upon the abov mentioned property farlapnxionpurpoxe. ALTPRORADDTOMEGH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertleo Date Receipt#
g.1 stbillBen,judgment,cost.anw
dexpeee which may In anyway amore AIR HANDLING UNIT(TO 10,000CIM) SUBTOTAL:
✓^xg(g�tlla,xIdd C�Ry In consequence of the anti n of thl.permit.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
S 9
Signature of AppE /Comrador Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ROCeI t#
material as defined by the Cupertino Municipal Cade,Chapter 933 and the -
Health Safety CedSection,Section 2SS32(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑
f�wry
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP CIHP OR 100,000 BTU) AW
4hYea .�r��s�ddorus g 1990
aif read He fie sous Code,S dkmlrcerenb5533 anCho pter 255346.95 of BOILER-COMP OVCR 100,000 BTU) (a
the California Health If the
A,Safety Cade,net currently
a tenant thaurdet
respntanlltyt.fthethe. Pont note nquomnots which
that It/set NEW RESIDENTIAL MfEIN. SQ.Ff
rnor Vie l.to rrul Ry the ompant of the requlremenb which must be ml
prior Issuance ofa Cedi(Icate o(Omp Cy.
O.vner ur au ior(u en Date ISSUED BY:
TOTAL
OFFICE COPY