20572APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buiidln Pry ect ILentlnaminn .-
Buildleg Address: fC/�Jp d -'Tc l%C/ S -E/�
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PERMITNO.
20572
nero ane: one:
APPLICA IION SUBMI I I p L DAM.
CITY OF CUPERTINO-BUILDING DIVISION'
APPLICATION / PERMIT
�
C traa raN,me Lie. No:
/O �e 6635
I Architect/Enginmr: Lie, No:
BUILDING-ELECTRICALMWBINC-MECHANICAL
CATEGORY
CONTROL N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
1''^
Addresa:�0. �X 6 S JFfAI /J /,Sp
PpthgTISSUANCE
® ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
Iherchyaffum that l am licensed under provisions of Chapter 9(commmc
Ingwilh Senlollformand effect. oftheguslnessandl'rofesalonsCode,and my
license h LoxP- fume and effect.
License Ch�-ti C -v LI<.N SCS
Datel,-/fa-9• Contractor ucGGaGNX!_aJAT/44, 2p
APPLIANCESRESIDENTUL
PANELS
UP TO 200 AMER
]OB DESCRIPTION
�� q
/\)
,
ARCHITECTS DECLARATION
I understand my piamshall be used as public records.
201-1010 AMPS
OVER1010AMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
SIGNSE TRICAL
Licensed Professional
WNER-BUILDER DECLARATION
0gPECU
Ihembyaf =tt I amexempt from the Contractors Llmrw Law for the
C I➢T/
PM O LE N
following .... (Sedfon 7031.5,Buineseand Professions Code: Any city or
county which requires a permit to construes, alter, Improve, demoltsh,or repair
any structure prior to Its Issuance, also requires the a pplicant for such permit to
file a signed statement that fie b licensed pursuant to the proWioro of rite
Contractor's License Law (Chapter 9(commencing with5mian 70W) of i-
ston3 ofthe Businesaand PmfemioroCode) or that hehexempt therefrom Yd
the basis for the alleged exemption. Any violation of Bectlon 70315 by
applies permit subjects the applicant to a civil pevlty of not morel n
five hundred dollars ($500,
I, as owner of the property, or my employees with wages ae tMlr so
D
5
E
C
VALUATION
, Y O
'1—s
C—W ^
REBID AL EL SQ.Ff,
STORIES
TYPE CONSTRUCTION
ill dot theand the
compensallon,willdothe week, and thestrocturehnot Ntentled or offend or
1
sale (Bee.7044, P,
Code:TM Contractors Lice me w
'
does not apply to an owner of property who builds or improves therein, d
who doessuch work himself orthrough his own employees, provided that such
OCC.GROUP
RES. UNITS
Improvements arenot Intended oroffered for sale. If, however lhebulidleg m
improvement b wld within oneycarofcompletioq the owner-budderwlll ha
t�rdon of proving that he did not build or improve for purpose ofe .).
I, as owner of the roe y g w
property, rty, em exclusively contradict with licensed
contractors to construct the project (Sec 7094, Business and Professions Code:
TOTAL:
QTY. PLUMBING PERMIT FEE
pERM[T ISSUANCE
FLOOD TONE
APN
The Contractor's License Law does no apply to an owner of property who
Wilds or Improves thereon, and who contract. for such pRnjeetn with a
c,n.ctor(s) licensed pursuant to the Contractor's License Law.
LI I am exempt under Sec B & P C for this reason
ALTER -DRAIN &VENT- WATER (FA)
gpCR FLOW PROTECT. DEVICE
PEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y— N_�
#
Owner Date
WORK MAN COMPENSATIONRECEW
DECLARATION
❑i hereby affirm that I have to of consent m tnsurc, c9 a
SCHOOL TAX Y N
cemficabc.) ,ken Camparuatloniwurance on certified copy therco!(Sec.
o lmum py
380ley# C3
RECEIPT M
GAS EA. SYSTEM -1 INCA
PARK IEE Y— N—
ley p
RECEGAS
Com any /R _ p/U
EA. SYSTEM -OVER
DING DIVISION
BUILDING DI VISION FEEB
CerlRed copy is hereby thM d.
Ceitied copy b tiled with the
-Irtcity
�cicity inspection division.
GREASE/NDUSTRL WASTE INTERCEPTOR
PLANCHECKFE•E
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not b. completed If the permit b (Drone hundred dollars
($100or rtifytJ In the
Iceam.mtoye.y Pa..1 an t...a, ass whichthispermit 1. Issued,
I shall not empty any person In any rtuI w u to become subject to the
Worken CoR�p neation Laws pf Gllfornla. Date/y-/ru
AppliNOTICE 116Lt F,YTf, after
NODd become
a subje t to t: a after making this ction Certificate Exemption, you
shouldbecome forth tot he Work en Compewtlonprovhis p ofthe Labor
deemed mvoke(orthwith comply with such provblomorthls permit hall be
deemed revoked.
PAID
Date Rcm t#
P
SEWERSANITARYSIORM EA 200FT
WATER HEATERW/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Remi t#
WATER SYSTEM TR
/ EATING
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
B FE
SEISMIC FEE
l�
CONSTRUCTION LENDING AGENCY
Iherebyaf0rm that there is a construction lending agency for the perform
once of the work for which this permit Is Issued (Sec. 3097, Civ, C.)
TOTAL..
FEE
Landers N.
lamice.Adder.s
certify that I have read this application and statethattheabove information
Qry. MECHANICAL PERMIT FEE 'MECHANICAL
PLUMBING FEE
FEE
FEES PAID:
Is cernect, I agree to comply with all city and county ordinances and slate laws
PERMITISSUANCE
relating to building constmelon, and hemby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmlesv the City of Cupertion
against liabilitkre,Pdgerents,emmand expenseswhich mayln anywayaccrue
against said City inon�ryuence of the granting of this permit.
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date Re ei t#
SUBTOTAL:
AIRHANDLING UNIT(OVER I0000CIM)
CONSTRUCTION TAX
Signature cl Applicant/Cont—rano, Date
EXIIAI)ST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
-
HEATING UNgT(20100,000 BTU)
Willtheappllontorfutum budding occupant storeorhandlehavardous
material as deflned by the Cupertino Municipal Code, Chapter 9.12 and the
Health and Safety Cod ion 25532(a)7
❑ Yes No
Date RCCCI t#
HEATING UNIT (OVER 100,007 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the applicant o future building occupant useequipment ordevices
which emit hazardous alrcont "cont... dented bythe Bay Area Air
�ialIty Management Dist /
BOILER -COMP OH'OR 100,000 BTU)
4 Yes o
am
BOILER.COMP&ER 100,000 BTU)
ove read the haz
le ous materials requirements under Chapter 6.95 of
the California Health &SafetyCode, Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a I4111,1113my
the occupant of the co'cherrcnbwh�pctanceoCertpantyCI'7()f
O �(ino
PUG
r(799resIlitytoorally
rIfIfIrt/f1Ownerorauthorlad
ISSUED BY:
NEWRFSIDEN7IALMECH. SQ.FT.
lint
TOTAL:
OFFICE COPY