20779 APPLICANTTO F IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build in emlflcation I PERMIT NO.
B°ilding nadreaa:
20779
one. A A A
tPt n, 'Vl, a^p , CITY OF CUPERTINO-BUILDING DIVISION _ rysa
Gontadora ame: Lio I 2
No: APPLICATION PERMIT 0—CttV
�3�z
BUILDING-LLECTRICALPLUMBINC-M[CIiAMCAL CATEGORY CONTROL p
Architect gineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
naamaa:(a2ZIo Shy( „aaAL PERMITISSUANCE ❑ ❑ ❑
LICENSED CON ACTOR'S DECLARATIOIJ
I hembyaRirmthat l amlcrosed under provelons of Chapter9(mmmenc- APPLIANCESRF_SIDENTIAL JOB DESCRIPTION
Ingwlth Svctkm7000)of Divlslon3Ofthe Busloessand Proficto onsCode,and m
license Is In full form end dfect. PANELS I �' ��jj �`
License CW®[ �j_Co M� �R R.�
Date -1Lic%# nor
ARCHITECT'S DECLARATION
:201-10070AMPSI understand my plans shall be used as public records. S SQ.FT.FLOOR AREA S/SQ.FT.
Licensed Pfessional ICAL
� OWN"_R-BUILDER DECLARATION fT/MISC7 F,rv..f, IherebyalRrmthtlamexemptfromthe Contractor's LlmnwlawforthepO following reawn.(Sedfon 7001.5,Buslnessand ProfessionsCode:An tl orFf'W countywhichrequlresapermltmconstmd,altenimprove,demolth,ormpair R POLE IN A.",
anystmc mprlormitt anc,alsoreq imstheappUontforsuchper tto
ilk a signed statement that he t Icenstd pursuant to the provisions of the POWER DEVICES
Ow Contractor'sLlcenselaw(Chapter9(commencingwith Sedton7OW)of DiA- SWA1h9NG POOL EI.E C
go03 ofthe Business and ProfessionsCode)orthat he is exempt therefmmand VALUATION
6.5 the hast for the alleged exemption. Any violation of Section 7MI5 by any OUTLETS. ETES ES Qom'
applicant for a permit subjects the applicant to a civil penalty d not nnre than s$ co.five hundred dollars($500). NEW RESIDEN I ELECIR
],as Owner of the ro SQtT. STORIES TYPECONSI'RUCTION'
�n
.F-1 p perry,or my employees with wages r<Mb sok
7a c Occ.7on,Busio the ness
and rk,Pr and the ns Code:
e Is he ot IntendedCcauactme orofferedLar a
O sale(Sec.appy to alnow and Professions Code:The Contactors Lves icense law
S� don doot es
loan imsciner ofpropertyrough whoa ilchl emorlmproovided that such
GROUP RESUUNITS
whodoe eatsucIn an not eve dee orough hisOwnemployee,provided t icing h
Improvementarenot Intendedoroffed plejo.ILh ner-q gder illn ve TOTAL:
Improvement pros within Oneid not Wild oriImpro Improve rpose of sl have
tTI.,puLas weer of theng phedldna exclorimprovefacting uolcense QN. PL BI FEE FLOODLONE APN
Ltr L as owner of the property,am exclusively contracting with Is Coca PERMIT. CE
ThecanCo costo construct the Law
(Sec.appy Business and Professions ore Code:
The Contractor's License Law dcee not apply to an owner d property who ALTER-DRAIN VENT-WA
Wilds Or Improves thereon, and who contcta for such ploject with a (EA)
"Nactw(s)licensed pursuant to the convectors License Law. FEE SUMMARY
I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE
Owner Date DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
I hereby affirm that I have a cortlRate of consent to self-Insure,or MT(�S P' SC
PER TRAP TAX Y N
B1ate of Wor1rs COmpensatiOn Insurance Ora certified copy,thereof(Sec. RECEIPT If
S
3800,Lab C.) GAEA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy _ _ GAS EA.SYSTEM-OVER4(EA) RECEIVE#
�❑pMiled copy t hereby fumished. �naf `S BUILDING DIVISION FEES
❑Cenlfied copy is filed with the city Inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPf1ON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(TM1tsectlonneednabecompleted iftheperrrdt tfor Onehund ddollars SEWER-SANITARY-STORM E.A.XpR. Date Remi t1Y
(E1 umfyss.) in WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certlfy that employ
an person In an the work fo as to b comehis evnit is to th, N—
I shall rs employ any person In any naer so u to become subject to the
Workers'Compensation Laws of California.iDate WATER SYSTEM/TREATING PAID
O Z Applicant
ZO NOTICEco APPLICesubjo to
after making ptastion Certificate Exemption,you NEW RESIDENTIAL PLMB. SQFT. Dote Remi HI
should become forth to the Workers'such p r vial n provtis p of the Labor TOTAL:
LU~ N Code,You=at forthwith comply with each provtlons Or this permit shall be
> deemed revoked. BUI ING -E 9T.06
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE t
SO
I herebyafirmthat there is a constrocion lendingagency forthe perform,Z anccotthe work for whichtht permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
O O Lender's Name PLUMBING FEE
LL ~ Lender's Add., QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iarillythatlhave read this appBatlon and wtethattheabova information
4 Is cord.l agree to comply with all city and county ordinances and mate Taws PERMIT ISSUANCE FEES PAID:
} 00 relating to building construction,and hereby authorize representative is
I— Z city to enter upon the above-mentioned property,formapecLOn purpose. ALTFRORADDTOMECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgment,coosand expenses which may In anywayaccrue AIR HANDLING UNIT(TO/ - 10,000 CIM) SUBTOTAL:
ugahut said City Inf° ryuena of the&i�ting of thh.pe it.
AIRHANDUNGUM7(OVFR10,"CTM) CONSTRUCTION TAX
Signaty o Applicant/Contractor / T /D to EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllant or future building occupant store orhandle harardom HEATING UM7(TO100,00OBTU)
matrulasdetinedbytOcC pertlno MunidpalCode,Chapter9.la,andthe Date Recel t#
Health and Safety Code Ion 2553T(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant rfuture building occupant useequipment ordevices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emithavrdo sair ntamtnantas definedth he Bay Area Alr
Quality Mavgement Dis ctT BOILER-COMP pEII'DR 100,000 B7U)
Yea No
haveradtheh ous materials requirement under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) w�`
the Gltand that
Safety Coes not oons T5505,SS33 and thitt i i ?-&
understandthat if notify buildingdoesof to requir haves whichLthat It troy NEW RESIDENTIAL MECH. SQ.FT. Ir�J
rapr to Issuance
canonfytheceapantoftherequirement which muse be met
prior to Issuance ofd Certifiate of Occupancy.
Owne.... thonud agent pate
i00
TOTAL: ISSUED
OFFICE COPY