20635 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Addrcm: 20635
Ott /OSaa v
wnera came': / C / one: p _A
la'27u/ GLV �Myr rn $64-7,410 CITY OF CUPERTINO-BUILDING DIVISION _ �•-��
Cono-a .Nam: T 3� + Lic.No, APPLICATION / PERMIT•:'
Arc tett/En ser. BUILDING-ELECTWCALPLUMBING-MECHANICAL CATEGORY CONTROL
Lic.No
YI f S ic.No�'//yr qTY - ELECTRIC PERMIT, FEE BUILDING PERMIT INFO
Addmac: `, Cmcy,,Sd17 'P6141IID PEIMTISSUANCE -
LICENSEDCONTRACTOR'SDECLARATION
IhercbyaHlrm that l am licensed under provisions of Chapter 9(common APPLIANCESRESIDENTIAL JOB DESCRIPTIONmgwlth Section7X(])of Divbdon3 ofthe Businemnd P
arofen lonaCode,and my `/
license Is Innse NB force and effect. - PANELS 1 l//vdeT�
LimCbm LIcA .../// \ ` e
Date Contactor
=1121 MO AMPS201.1000AMPS 6�/ K er
ARCHITECTS DECLARATION
NZI understand my plana shall be used ss public records. OVERIMOAMPg SQ,FE.FLOOR ARA $/SQ.FT.
q��++ CO
Fe�(0 Licensed ProfProfessionallotul
<�<kL'Z� OWNER-R UILDER DECLARATION - SIGNSELECTRICAL SPECIALCIRCUITZMISC
Z f,'�3 I hereby affirm that l am exempt from the Contractor's License Law for the
O F• following reason.(Section 70115,Business and Professions Code:Any city or TEMP.MUTER OR
P countywhlchmqutmsapermlttommtmct,alter,impmve,demlish,orrepair
anystructure prior to inissuance,also emplresthe applicant for such permute POWER CES J
r✓E file a signed statement that he is licensed pursuant to the provisions of the
Contractor.License (ChapterLaw 9(commandin with Section 7000).fDlvl-
�-•.00H' sion3ofthe Business and Profeions Code)orthatt he le exempt therefromand SV,TMMIN LEL RIC VALUATION
YI S the basis for the alleged exemption. Any violation of Section 70715 by anye �+
<e. applicant fora perrtdt subjech theappl)cant too civil persltyaf not mre
ottur, O�•El' !%J a
five hundred dollars($500). NEW RESID •L SQ.FI. nowtiliTYPE CONSTRUCTION
�m ❑I,as owner of the property,or my employees with wages as their sots
compensation,will do the work,and the structure Is not Intended or offered for
qsale(Sec.7064,Business and Professions Code:The Contractors Llmnse Law
32 does not apply to an owner a property who builds or improves therron,and OCC.GROUP RES UNITS
EE whodoessuchworkhlmselforthroughhlsownempleyeesprovided thatashIr
Improvements arc not intended attracted for sale.If,however,thebuliding or TOTAL:
Improvement emold within one year ofcompleliom the owner-buBderwlll have
tlkekurden of proving that Im did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LJ FLODDZONE APN
L as owner of the property, Se exclusivelyuse contracting with licensed PE MITISSUANCE
contractors to ro Lt..the project(Sec.70 pr'Business and of propertlaminesy
Code:
The Contract.,'.Improves
License law does not apply to an owner a(property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereua and who contracts ice such p(ojesb with a
,,0a.t{(actw(sexempt under Sec.
tothe Contractor's License Law. BACK FLOW PROTECT.DEVICE � FEE SUMMARY
LI7 am exempt under Sec. B &P C for this rcawn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N' :
• Owner Date RECEIPT If
WOR gNAN COMPENSATION DECLARATION FIXTURES PER TRAP 5CIIDOL TAX Y_ N_
❑I hereby affirm that I have o Insurance
a c of consent to epytheuse,ora RECEIVER
certificate of Workan'Compensatlon Wuance ora certlfkd ropylhereof(Sec.
3800,Lab C) CAS EA.SYSTEM-I INCA OUTLETS PARKFEE Y N
Pollryp GAS EA.SYSTEM-OVER BILI IN
Com any BUILDING DI VISION FEES
❑pCertlRed copy V hereby th the cityad, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed copy V filed with the tlly Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT Date Recei t#
(this settlors need not be completed If the permit V forone hundred dollars
($100)codify ththeat
WATER HEATER W/VENT/ELECTR - ENERGY FEE Y N
I anet thato the Person
any
for which this permit is booed,
1 shall not employ any person In any manner co m to become abject to the WATER SYSTEM/TREATING
Workers'Compenaatlmn laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi I#
Z Q NOTICETO APPLICANT.H,after making this Certificate of Exemptlon,you
should b come subject to the Workers'Compensation provisions of the Labor TOTAL:
CN Code,you moat forthwith comply withaich provisions or this permit shall be DING
W > deemed revoked.
a C FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmtlot there Is a construction lending agency for the perform- ELECTRIC FEE
D Z ante of the workfmr which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
V Q Lender.his PLUMBING FEE
LL I- Lender.Add mm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have read thisappli itlonand statethat the above Information
C bcorret.l agreelo complywlth all city and 0
county ordinances and state laws PE6MLSSUANCE FEES PAID:
>. N relatingtobuliding construction,and herebyauthorlu representatives of this
(— Z citym enterupon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. _
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,mstaand expenses which may In anywayaccme AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL: ,G
against said City In consequence of the gaiting of this permit.
AIR HANDUNCDNgT(OVER 1o,(nocFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle harardms HEATING UNIT(TO 100,000BTln
evocdalasciefined by the Cupertino Municipal Code,Chapter 9.12,andthe Date Remi (#
Ilealth'and Safety Code Section 25532(a)7 I FEATING UNIT(OVER 100,000 BTU) TOTAL: �Z
❑Yea No npnw��
Will the applicant or lure building occupant use equipment or devious VENTILATION FAN(SINGLE RESID) IS§d#AIIDATE
which emit haaardous air contaminants as defined by the Bay Area Air
i�
Quality Management D❑Noistrict? BOILER-COMP OHP OR 100,0(0 BTU)
4Yes N JUNz 81990
havereadthehaaa oua srutodals requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU)
the Califomla I ieelth&Safety Code,Sections 25505,75533 and 25534.1 �ssas{
understand that if the building docs not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. �V asR�
rmponsibllity to notify the occupant of the requirements wh lch must be met u cu
prior to issuance of a CertlRate of Ocmpanry.
r- C
Ownerorauthorlaed agent Date ISSUED B . &' T ✓�L/
TOTAL:
OFFICE COPY