20139 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildlnR Project Identification PERI%IIT NO.
Build Ing Address: 20139 -
I LJ C> c_\ +
ame. ane. . S .1 A A
Jeri 0 CITY OF CUPERTINO�BUILDING DIVISIONAd _ G
ContredaisN ' i Lir.No: APPLICATION I PERMIT _ I
L CT • '1 BLnl)I.NGnECTRICALPLUMBI\C, EC NTCAL CATEGORY CONTROL N
nmhitm/Fsgineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: !'� r PERMITISSUANCE NiMia
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l am licensed under provisions of Chapter 9(commere, APPOANCES.RESIDENTIAL )OB ULSCR ON
ingwlth Sectian7000)af Dwision3ofthe Busin.,tr d Professlom Cade,and my
license is 1. T
farce and d(m, PANELS �
Limns YClanlass Lich .-5 �a10
Date -/7�Contndor / .'..icia
ARCHITECTS DECLARATION Go'>V,a//e,( 201-1000 A.MI'S
iOZ (understand my p6m slugWusd vpubticremds. Bsstd, OVERIWOA.MPS SQ.Fr.FLOOR AREA $/SQ.FT.
O
Lu, Licensed Professional SIGNS ELECTRICAL ® *1
—<- OWNER-BUILDER DECLARATION R
n—o SPECIAL CIRCUIT/MLSC
GZ owingrason. Wtlam31.5,Bfrom
esthe
sad ProfdoraLivens Law fort he
D=— folowing remon.(Section rmi1.5,construct,stress and Professions,Code:Any tlep or
4,r.^]. TEMP.METQi OR POLE IN T
_� reuntywMch requires.permitsoorecttestheaprovgdemoilah,or repair }
any structuretatemeprior to itshat he Is aborequUothettot the
provisionor such s
of to POWER DEVICES Igo
j`Y—'< Wof
file a signed statement that he b Icensed pursuant to the provbiom of Me \!
�C5 Comrartor's License Law(Chapter 9(commeicingwfth Section 7000)ol Divi- SWIMMING POOL ELECTRIC DATE
'C tion3ofthe Businessand Prof.ssW Code)orthathebexempttherefmmand VALUATION
V, the basis for the alleged exemption. Any violation of Son]QHS loby any
< applrantfora permit wbjecv the applicant toadvil penaltyo(na more than OUTLETSSWITCHESFIXTURES
five hundred dollars(SSM,
^�+ NEW RESIDENTIAL ELECTRFT.
7 6 ❑i,as owner of the property,or my employees with wages as their sole SQ STOWES TYPE CONSTRUCTION
compensation.will do the work and thestruCure Is not Intended or offered for
U0 sale(Sec 9014,Business and Professions Code:The Contradoes License Law
j5 2. does not apply to an owner of property who builds or improves thereon and OCC GROUP RES.[PVITS
who does such work him elf or through his own employees,provided that such
Improvements arc not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement issold withinoneyearofcompietl theowner-budderwill have
th,,aardenofpmvingthat he dm nwtbuud or lmpm.-e for purpose ofsale.). QTY. PLUMBING PERMIT. FEEH.mDZO, ArN
LL_J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE I�t .ar
osntndon to comvuet the project(Sec 9044,Businessand Professions Code: lOJ
The Contndar's License Law don not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilds or Impm,m thereon, and who contracts, for such p\geds with a
Cc tndFEE SUMMARY
or(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B &P C for this reason
nen DRAINS FLOOR ROOF,AREA,CONT). SANITARY Y N
Date RECEIPT p
WORKMhat COMPEVSATION DE onset ION F�gps PER TRAP .^.�,al�� SCHOOL TAX Y— N_
❑I hereby affirm that 1 have a certiRote of consent to uhf-Nwrc,ora Zx W �N
cM.LateolWorken'ComperuationImurance orattnifled copythemof(Sec. RECGAS EA SYSTEYSI LNC4 OUTLETS PARKFM Y N
Policy
Cd 80 _
rY q RECEIPT N
Com any S C d IG GAS E.A.SYSTEM-OVER 4(TA)
gZ fied copy b hereby fumlshed. BUILDING DI VIS ION FEES
MCendled copy is filed with the city inspection division. CREASE/INDUSPRL WASTE IVTFRCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP
COMPENSATION INSUPAID
(TNasmlon need riebecompleted lithe permit ofoone hundred dollars SEWER-SANITARYSIORM(EA 200FT
Date Remi t#
(3100)or lathatss) WATER HEATER W/VENT/ELECTR ENERCYFEE Y N
I cent emp to oy he any Femn in ead any neerwork or to b this permit ie owed, —
Ishag not employ any perwn In any rtunner so n to become wbject to the WATER SyltTEM/TREATING
Workers camEeration laws of Califomi PAID
Z Applicant(
. O
NOTICE TOAPPLICANT:II,after mngthb Cen m NEW RESIDENTIAL rL11B.ufEaemsimi,you SQ}T. Date Recei t#
should became subject to the Workers'Compereatlon provbiom of the Labor TOTAL:
N Code,you mustfanhwtth comply with such provisions arthis permit shall be
7 deemed revoked. BUILDING •E
O CONSTRUCTION LENDING AGENCY
ance SEISMIC FEE _
i Z Ihereby affirm that there bm
a cotrudlon lendingagency forthe perform ELECTRIC FEE
of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: �L{o61 O Lenders Name
Lcndce Addrem QTY. MECHANICAL PERMIT FEE PLUMBING FEE -6
U Ittrtlythati have read appBcetionand xatethanheabove Information MECHANICALFEE
W bcorntt.I agree to comply with all city and countyorein.ncm.rd state laws PERMIT ISSUANCE FEES PAID:
U) rel.tingmbulldingmmtmctlogand herebyauthory<reprnentstivesofthb
Z dry to enter upon the above-onctloned property for inspection purpose. ALTEROR ADD TOMECH.
(We)agree to save,Indemnify an d keep harmless the CIy of Cupertino Date Receipt#
agalms liabilities,jodgmenb,comsand expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
against gild Cly in consequenceof the granting of this .it.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slgwmreof AppilcAZAR ntoctor Date
HAZA ROODS MATERIALS DISCLOSURE at LAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
re
Will the appliunt.,heuprtino gompantmom handle and the HEATING UMT(TO300,0(10 BTU1
materiaHealthlasdafinedbythediw, 2(a)?iripalGode,Chapter 9.12,and the _ Date RCCCI t#
Ileltheit SafetyCode Sadlon 25532(.)? HEATING UNIT(OV[R 100,000 BTTO TOTAL: 10
❑ Ym �No
Will the applicant orfutnre buildingoceupant use equipment ordevueS VLYTIL\TION FAN(SINGLE RESID) ISSUANCE DATE
which emit haxandom air contaminants as defined by the Bay Arca At,
lily Management District? BOILER.COMPOIPOR 100,0M BTU)
ye, 1�No l�PAMPAMP
have mad thehua�ous materials requirements under Chapter 6.95 of BOILER CONIP(OVER 100,000 BTU)
the Glifrnia!lealth&SafMY CW e,Sect IOm 25505,25533 and 25534. 1 )
understand that lithe building does not mmandy have a tenant,that it b my hT:lY RFSID[NTIAL MECH. SQ.FT.
rsIxi iliy to notify the occupant of the requirements which must be met
prior to Issuance of a Cmiflc,im of Occupancy.
Of rIlI1P1t1
(Tuner or auNonud agent Dare
TOTAL: ISSUED BY:_11
OFFICE COPY