20436 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
was:
Building Project Identification PERMIT NO.
Ba"°'ngAdd - 20436
wear's
paten-. - A
STe►a.RNS � Q CITY OF CUPERTINO-BUILDING DIVISION S`I e—`�a
eDno-atar.wrse: ase.ND: APPLICATION / PERMIT 1,
TION �' SS 67 ,APPLICATION
CATEGORY CONTROJCNQ
Arctect
hi /Engineer. Lic.N. ((((�� o
CITY � • ELECTRIC PERMIT FEE 'BUILDING PERMIT INFO
Address: PERMBTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provWons of Chapter 9(communc APPLIANCES-RESIDENTIAL JOB D ' M-DON
ingwlth Sectlan7000)of DIA9.3afthe Busineuand PrefesumaCode,and my
license I•in full forte and affect. PANELS
Liceree Class Lk.N � /
Date Contractor
ARCHITECTS DECLARATION Ml-1000 AMPS
pV I understand my plam.hall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
u1 O
Licensed Professional SIGNSELECTRICAL
�Q OWNER-BUILDER DECLARATION SPECfALCE2CUIT/MISC
ZE, Iherebyaffimnthat l am exempt from the Contractor's License Law for the
QQ following master.(Section 70315,Business and Professions Code:Any city or
r1' u{ cmnlywhichmquimsapemdtiomn•tmd,alter,impmve,de=lish,orrepalr TEMP.MEIT72OR POLE INST.
�a`a a any,t tlMmpdri.iGiswane,aLw.qul..theappH.ntforsuchper ito POWER DEVICES .
O file a signed statement that he is licensed pursuant to the provisksm of the
Contractors Lica—Law(Chapter 9(mmmendng with Section 7000)of Dlvl-
i-�3 0 swu(MENc Pool¢ecrRlc
sion3 of the Business and Profenlora Code)Druhat he is exempt Iherefromand VALUATION
ES Sn g the basis for the alleged exemption. Any violation of Section 7031S by any O�
applicant fare permit subjects the applicant to a civil penalty of net marc than OUTLETS-SWITCHES-FIXTURES `
five hundred dols.($500). NEW RESIDENTIA ELECTR SQFT. .
'9..' ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
C compensation,will do the work and the structure Is not intended or offered for
5 O as Is(Sec.7094,BwUus•.ad Pmfesslow Code The Contractors Llcewe Law
�e s
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUT' RES.UNITS
who doessuch workhlmself orthrough hisown employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebuilding orTOTAL: l
Improvement bsold withlnoneyearofcompldioMtheowner-bullderwiil have
01LIlunden of peaving that he did nwbolld orleopmewforpurposeofule.). QTY. PLUM -RMT FEEp1pp z,p AAPN
L as owner of the property,am exclusively Contracting with limned p ISSUANCE
mnt.Rom to contract the project(Sec.70K Business and Pro(emloru Code:
The Contractors License Law does not apply to an owner of property who ALTER- IN& WA
Wilds or Improve•thereon, and who contracts for such ptcjets with a
cgLI Rt(actor(s)licensed pursuant to the Contranor'•License Law. BACK License EVICE 'FEE SUMMARY
I am exempt under Sec. B&P C for this mason
SANITARY V N
OUTSIDE ITES
Owner Date - DRAINS- AREA, RECEIPTa
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self-Insure,ora pyXIT2gEq PER SCISOOL TAX Y_ N_
RECERT N
mtlfimteofWork WCDmpematlonlruuranmoramrtiflad mpythereof(Sec.
38W,Lab CO GAS F.A.SY - ING.4G E15 PARK FEE Y N
Policy I GAS EA.SYSTQd-0VER 4 RECUPT N
Cam any BUILDING DIVISION FEES
�Certlfiedcopyisherebyfumished. GREASE/INDUSIRL WA 1]' PLANCHECK FEE
CDCedified copy is filed with the dtyimps tion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID ��--//
COMPENSATION INSURANCE SEWER-SAMTARY-STORM U.2l10FT. Date Recei t# 7b. 0
(Thin section need not be completed lithe permit b forot hundred dollars
($100)orhas.) WATER HEATER W/VENT/¢ECTR ENERGY FEE Y N
I cetlfy that In the performance of the work forwhich this pemnit is Issued,
I shall not oon%V any peon In any manner an
a(1)i_ to.the WATER SYSTLM/TREA77NG
Workere'CompeAsatloo.�q>Xeof lifomb. Date _ V PAID
Z 0 NOTICE T0�'A I'+L�\ rANT•:If`after making this Certificate of Exemption,you NEWR�DLNRAL PIMB. SQFT. Date RCCeI f#
Fshould become subject to the Worke.'Compmuatlon previsloms ofthe Labor TOTAL:
cc N Code,you most forthwith comply with such provision orthb mi
pertshall he BUILDING
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihembyafflrtnthat there ba construction lending agency for the perform- ELECTRIC FEE
1> Z ante of the workfor which thisperent is bound(Sec.3097,Civ.C.) TOTAL;
02 Lender'shame � PLUMBING FEE
LL H lender'.Address QTY. MECHANICAL PERMIT' FEE MECHANICAL FEE
.0 W l rertlfythat l have read thisappllratonand statethatthe above Information
fIsmmed.Iegreeto complywilh alleityand county ordinances and state laws PERMITISSUANCE FEE-PAID: ,
7. relating to building construction,and hereby authorize reprnentatives of this
N
F Z city to enter upon the above-mentioned property for Inspection pu rposes. ALTERORADDIOMECH.
V — (Wq)agrre to save,indemnify an d keep harreess the Cityof Cu pet it Date Receipt#
agalrut bl J\II\ties,judgments,"as rad expenses which may litany way accrue AIR HANI)LINC UNIT(TO 10,"CFM) SUBTOTAL:
agabstu City(�mnsequen^rep f the g.ruing of this permit.
o \,tel , AIR HANDLING UNIT(OVER mocalcm) CONSTRUCTION TAX
Sigratorcof Applicant/Contvto Data EXHAUST 11001)(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBmnt orfuturc building ocmpant•tow or handle hazardous HEATING UNIT(TO 100,000 BTU)
rtaterlAtis defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Receipt#
Health and Safety Ccde,Wtioo 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: I
71Yes I`I I No
Will theapplimnt up feet.building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air trtamirants a•defined by the Bay Area Aire
Quality Management D 12 BOILER-COMPC311POR 100,000 BTU)
Q Yes No
,hxvcreadthehazy ous letalsrequirements underChapler6.95of BOILFR-COMP(OVER100,000BTU) 1990
the California I lealth&Safety Code,Seniors 25505,25573and 25534. I 15
s�
understand that if the budding does tt currently have a tenant,that It b my NEW REST DENTIAL MECH. SQJ,7. ( rtj L:, !�
roPoml Illy' o Ctheoccupant of the requirements which most be met
prior.7oc of a CetlfirataOccvpanry.
\ry -aY
Owne�ror Rfiorize" dagent� Date ISSUEDB .
TOTAL:
OFFICE COPY