20998 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildins,Proect Identification PERMIT NO.
Building Address: 20998
wenn a Phone:
. C /L OL) — W'YOFCUPERTINO-BUILDING DIVISION Q
C°" �° °Name: _ Lie. APPLICATION /PERMIT "�`- /
BUILDINGELECT'RICALPLUMBING-MMHANICAL CAITCORY CONTROL M
ArcMt /Engineer. Lic No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IherebyaRbm lMtlam Bcrosed underprovklons o(Chapter9(mmmme APPLIANCESRESIDENTIAL JOB DLSCRITION
Ingwlih Section7000)of Dlvlelon3o(the Butlnwand Pro(wlonaCode,and my
lice.kin fullfo ane effect. PANELS wr�
Lm
ClaLim«
.Date
Q_Contractor Y
ARCHITECTS DGCLARATIO 707.1000 AMPS
p❑+exZ l understand my plans shall be used as public rectors. OVER IOW AMPS f5R JEN $/SQ.FT.
oo
E 1z(� Licenmd Pro(emi°rul SIGNSELECTRICAL L {./
7�«<<.4FL`d+l Y OWNER-e UILDER DECLARATION SPECIALCI(CUIT/MLSC P VTC R
Ihercb affirm that l am exemptfrom the Contractor's License law for the ar
following reason.(Seale"io Xto Business and Pro(wkne Code:Any my or ®O/�'/�®
F t'�
following
tywhkh rcquiresion 703ttorosatmct,adPoffImprove,ons Codlkh,ority firor TEMP.MCTER OR POLE INST.
°'I a any structum prior to its issuance,also requires the applicant for such permit to
POWER DEVICES
O file a signed statement that he k r9(colicensed pursuant it the pro 700)) f the
Et
Cortisone.of the
License Law ndProfpter9(comrrcnMg withxSection
mptthe00)of Divi- SWIMMING POOL ELECTRIC VALUATION
H�Oa sion3o(the Buslnwand ProtwlomCode)orthat hebexempttherelromand S"•]] the bank for the alleged exemption. Any violation of Section 7031.5 by any
<
applicant for a peon subjects theapplicim to a civil penalty of not more than OUTLETS-SWITCHES /�
live hundred dollars($500), NEW RESIDENTIAL ELFCTR
n I,as owner of the property,or my employees with wages a,Their sok SQdrf. STOPJ ES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
sale(Sec.70K Business and Profusion Code:The Contractor's Lirerue Law
$ docs not apply to an owner of property who builds or Improve,Ihc=M and OCC.CROUP RLS.UNITS
who doesauct,work himself orthrough his own employees,provided that such _
improvemenk are not Intended orolfered formic.IL however,lhebulldingor TOTAL:
Improvement is add within oneyearo(completlon,the owner-builderwill have
t"relen of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lf[as owner of the property,am exclusively contracting with licensed
contractors to construct the projecl(See 7044,Business and Profusions Code: PERMrrISSUANCE
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VFNE-WATER(EA)
builds or Improve thereon,and who contrafor such plojects with a
cgR�actm(.)homardi pursuant to the Contractor.License Law. BAER BLOW PROTECT.DEVICE
FEE SUMMARY
I_J I am exempt under Sec B h P C for this reason
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
OUTSIDE FFrS_
Owner Date RECEIPT
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
—40 1 hereby affirm that I have a mrtinnfe of consent to pytheure,or• RECEIT N
3800cedilAb of Workere'Compesaatlonlnsurance oracertlfled ropy thenrof(Sec. GAS EA.SYSI'EMIINC.40UTLEPS PARK FEE Y N
TO Lab C')
Polley« ��/T��j ria BUILDING
Cam ae CAS G.SYSfCM-0VER4(FA)
7 /(�T L BUILDING DI VISION FEES
E:(go ifie copy k herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�,pc nmearopyknkawlthlneeBywpemm�alwkmn:
7-
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ' SEWER-SANITARY-STORM P.A.700FT. Date RCCei t#
(fhb eectlon need mat be completed If the permit k forone hundred dollars
Iperformancelem.)
I
(certify that In the performance ofthewo54(orwhkh
hthie pemnitkWATER HEATIRW/VENT/ELECTR ENERGY FEE Y_ N_
shall not c�j to person In any ryan so es to become subject to led WA.fQt SYS.IDN/.I.RG.ONG PAID
Workrrs'C an minus la.
O Z Applicant_ ae NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE WA7IILIICANI: atte�� rmoWngthk enBlokof Excmpton,you
I" should become subject to the Workeri Compesaxtlon provisions of the Labor - TOTAL:
IN Code,you must fort hwith comply with such proWiosa or this pemdt shall be
> denernd revokrd. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a cosatmction lending agency for the perform~ ELECTRIC FEE
DZ ance,(the work forwhichthk permit b lawed(See.3097,Clv.C.) TOTAL:
0 O Lender.Name PLUMBING FEE
LLH Lneder.Addeesa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Inertifythatl have read thkapplication and statethatthe above information
f1 kcomed.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Nrelating to building construction,and hereby authonas reposentativesofthis
I— Z chyto enterupon the above,on,Honed property for inspection purposes. ALTER OR ADD TO MECH, Date Recei (#
I
(We)agree to save,Indemnify an it keep armless the City of Cupertino P
ag liabllitks,judgments, sandexpe w hichmaylnanymyacorue AIR FV.NDLINC UMi(f070,000 CFM) SUBTOTAL:
a I old Try in con (the gra n o(this pemnit AIR HANDLING UNIT(OVER IO,OpCFM) CONSTRUCTION TAX
SgratureAppII.n!/Co a err Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building orcvpant.tore or handle hararde., I iFATINGUMT(TO 100,000BTU)
material as dented by the Cupertino Municipal Code,Chapter 9.17,and the Date Recef t#
Hralthand Safety Cad Ion 755370)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: a
Yes No
Will theapplkant rebuild)ngoceupamuseequipmentordevice. VFNIILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit harardou alrmntandruntsaadeflned bythe Bay Area Alr
. Quality Mara gement at ct7 BOILER-COMP ptE'OR]00,000 BTU) ILiah n®
4 Yes No
have read theh ous maleriala requirerrenb undcrChaplcr 095 of BOILER-COMP(OVIB 100,000 BTU) OCTJ♦ np(�
the Califemla Ileal i Safety Code,Section,75505,25533 and 75534. I 1 N b 1�JyA
understand that lft building does not arrc have a tenant,that It k my NEW RESIDENTIAL MECFL SQ.FT.
repo r dllylmndl(ythc occupant d the ement.which must be met
prbr oars dace ccupa
,��� ' �e-�sy� gym. �` . .�
Owner or a-u�orrlud agent a Date ISSUED BY: •` p ILJ
TOTAL:
OFFICE COPY