20074APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'— USE BALL POINT PEN ONLY
- -
building project Identification
Building Address:-
'20030 e e s/ �re /�
P' IT NO,
20074
t/^ nnz.
- ,yyra a / QRS _
CITY OP CUP6RTIN0-BUILDING DIVISION
APPLICATION /PERMIT
BUILDING-ELFAIRICALPLUMBMG-MECHAMCAL
A
C)ortranoraN� NoL
ic."
V " A
t A t /Eng( er. Lie No
F C�
CATEGORY
CONT",{
D `/ 00
IQIY 'ELECTRIC-PERMITi!�Ir T�FEE t-'dL3;tIBUILDINGPERMIT
INFO,a-
Addmas/OD eLO F�/N a4L
d PFRMITISSUANCE \
LICENSF.DCO TRACTOR'S DECLARATION .
I hereby aRtrm that l am licensed under provisions of Chapter 9(oommen
Ingwithgedion7000)of Div Mon3ofthe Buslnessand Profen onsCode,andmy
license Is In (oil f and effect. `
License 1 -ss -
Date ContractorjjPTnX1fIAMPq
ARCHITECTS DECLARAT ON
(understand myplamshaRbeusedaspubilce, L
Licensed Prefeedoral
• OWNER -BUILDER DECLARATION
I hereby affirm that lam exempt fromthe Contractor.Llmnse L.awforthe
following reason' (Section 7031.5, Business and Profenl... Codei Any cityor
.w tywhlchrequlresapermittommtand,altegimpmve,deoalbh,orma it
anysvucture prlorto Its Issuance, also requlresthe appliantfor such permit to
Ole a signed statement that he b licensed pursuant to the provlsloro of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Doi-
oi-
'..3
slon3o(theBusinemandlro mioro Code)orthathebexempi tfierefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicantfora permit subjects the applicant to a civil penalty ofect morethan'
DOL
fiFIL asve ownered of the pro
I, as owner of the property, or m struck m is with wages r thele sole
cont nsalo wlllaothewor
pe M work, theawcture boot intended or offend for
sale (Sec, apply to anow and Professions Code: The Contractors proves License Law
does whodest apply loan owner ofpropertyhisoWtlds nemporees,prvided t oryand
whodoesuch work hbnself or through hisown employees, provided that such
Improvements amount intended orofkmd forsale. ILhowevcpthe Wildingor
Improvement issold within one yearofcompleiory the owner -W Bderwill have
The-tmedenof provingthat he did not build orimprove for purpose'ofsale.).
u L as owner of the properly, am exclusively contracting with Licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contrector's License Law does not apply to an'owner of property who
Wilds or Improve thereon, and who contracts for such p(ojects with a
Rtsolaria) licensed pursuant to the Contractor's License Law,
lL I am exempt under Sec. B & P C for this reason
APPLANCFSRESIDENTIAL
BDESC ON
_
/ �7er10� VPs at/
PANELS'
MI-l"AMP5 I
OVERL000
s(j. FT.ILOOR ARG
t
.
-
§/SQ. FT.
SIGNSELEC L
- SPECIA IRC /
TEMP. M E I
pOWERD
SWPIMI L IIC `
.''L /' ,,,
OUT. 7C FS' isW
D N L TR ,F f, -
t +
VALUATION
- dG
DCyj 0�a
STORIES
TYPECONS RUCTION
-
-
'\\
TOTAL: V
QTY, �; PERMIT( ti' I"
OCC.GROUP.
RES.❑M7S
-
_3i dPLUMBING
PERMIT ISSUANCE 1�
l
ALTER -DRAIN & VENT '- WATER (FA) s�
FLOODZONEAPN
'
'I'll;' SFEEISUMMARY" ''r:l 't
_ BACK FLAW PROTECT. DEVICE.
OUTSI DE �� re
DRAINS FLOOR ROOF, AREA, GOND.
FIX'NRF.S PER TRAP
SANITARY Y_ N
-
Owner Date
't WORKMAN COMPENSATION DEC LARATION
❑I hereby'afflrm that I have a l rt cone of consent d pytneure, or
3800,�diflabo(Workers'Compensatlon Wuranceoraartlfkd ropytfiereof(Sec.
Lab C3
Policy
SCI -1001, TAX Y��Np
RECEIPT It
GAS PA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
:GlD
vCAS EA. 9YSTEM-0VER 4 EA)
CETtY
BUILDING DIVISION
ISION FE[S
edlfedcopy Is filed Mthrthe city
❑Cealfled mpybfiled'Mth the city inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssection need nor Womplded(the permit b(oroneFondred dollars
(§l I mftifym.)
I ll net that emIn ploy an person in any tmonerhe so ax towhich comeesubjecrmit 1. issued,
1.hall not employ any person In any manner m ns to become subject m the
Workers' Compensation laws of California. Oats
Applicant -
shouldNOTICTOAPPLjCAN7:If,e aftermakingthisCtion preof Exempllo Labor
Labor
Code, becomeforth forthwith
CodGyou must forthwith comply with such provisions orthb permi[shall be
co Work ed Comproviinprovhis permit
aeenaca revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaf.th.tthereb...trudlonlcndingsgencyfortheped.,co-
ance ofthe work for which this permit bbeted(Sec. 3W7, Civ. C.)
Lender. Name
Lender's Addraes -
Icertlfyt6atl have read thisappllcohmmdelate that the above informmion
Is rorred. l agree toromply with all otyand countyoNlnances and state laws
relating to building ronslroction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes:
(We) agree to avemie , Indemnify ao d kee harthe City of Cupertino
against llabllitle,Ndgmenb, costa and ex mr.w meyet..ywayaceme
.gains I ity in con enaafth ruling t sp..mlt.
%D
'GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCI-IECK PEE
IAID �Dapte ll Recei t#
-(&
GREASE TRAP
FA. HpFf.
WATQt HEATER W/VENT/ELECTR
ENERGY FEE Y , N _
n 0
PAID Y OEL 5 g.
Date Recei t#
-
Z�3.�
WATER SYSTEM/TREATING -
NEW RESIDENTIAL PLM B. SQ.FT.
-
TOTAL:
BUILDING
-
SEISMIC FEE
OO
TOTAL: Q�
ELECTRIC FEE.
x O
..3 ,.; , r,4 , .,
QTY: pi ME_CHA_ NICAL�PERMIT`.:' ' ,l 'FEE p'
PLUMBING FEE
1.0.00;
MECHANICAL FEE
.00
tt
l PERMIT ISSUANCE 2,�
FEES - -
3, ALTER OR ADD TO MECH.
Date RECCI t#
P
-
AIR HANDLING UMT,(T010,000 CFM)
- SUBTOTAL:
AIR HANDLING UNIT (OVER I0,000CFM)
CONSTRUCTIONTAX
-
gnalureofApplHA7ARDnt r Dots
HAZARDOUSMATEoc SDISCLOSURE .
Will ia the appildefinen fitternbuilding ocapantoe, hhandle 9.IZ a rdous
Cupertino Municipal Code, Chapter 9.12, and the
material a Safety Code
I ayfiY 9d Safety Code, Sedloon 25532(.)7
111 the appllanl or Weebullding occupant use equipment ordevices
which emit hazard .... ir cont. rnearas as dented by the Bay Area Air
Quality Management Dot _ ,.
4 Yes No
have read the hoar nus materials requirements under Chapter 6.95 of
the C.lifornia llCode,Sedions25505,25533and255M.1
understand that if the building doesn currently have a tenant, that it is my.
responstbl to notify the occupant o the rcqu mutants which most be met
priortoiss counts stifiateo pan
'EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
-
HEATING UNIT (TO 1D7,W0BTU)
Date Receipt#
FIGTING UNIT (OVER 100,OOf1 B"fU)
TOTAL:
a�
' VIiNI RATION FAN (SINGLE RESID)
ISSUANCE/ '$
Is�
V/�f
s Q J7
! /99/]
�a -
LSSUEDBY: 'y`r e " �
BOMER-COMP pfIP OR 100,009 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
-�1�
`Z s s'r'v� gylp_ InOlz
nerd thodzed .gem Data
-
'TOrnL; Fb
OFFICE COPY