20539 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification Pi7LWTN0.
Building Address:. _
G f j O r^ n
o i i STL ►s , 'IG y ,Uf� 3l9J
wncn ane: "near:
.: , A A,
CJ •M ,/Lc . 1 2v�„ CITY OF CUPERTINO-BUILDING DIVISION
c�gyJ dura me:
N. APPLICATION / PERMIT
'pOa�T �'SS SIG�I103I BUILDINGELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROLp/I_. N
Amhtece/ gl er. �'
s �'�' _ , I t..,. s:•'.4.i ,r s _set;'I'-t4BUILDINQPERMIT INFO,11 ..
Aaareaa: �•-�(TN,• �I16�
QTY ELECTRIC PERINIT ,,., ilrFE..Hyy...�' .. ..
PERMIT ISSUANCE••' �,4a„,.� T `
LICENSED CONTRACTOR'S DECLARAT ON 1
I hereby aflrmthat I am Bemsed under provisonsof Chapter9 (ommenc- API'LIANCESRESIDENTIAL JOB DP ON
Ingwith Sduon7000)of Dlvlelon3 ofthe Busimssand ProfesslonsCods,and my
lianas,is In full! and died. PANELS - ""7�•`-0
lanae ss L .
Date �tf gQ_Contrador .
I
ARCHITECTSDECLARATION
OVER00A.M1'S
a02 lundentnnd my pUv shall be used as public recoNs. OVER 1080 AMP'S - F4.FT.FLOOR AREA S/FQ.Ff.
µp ❑O
E U() Licensed Pmfesslowl' SIGNS ELECTRICAL ,a a3 O a oO
< .OWNER-BUILDER DECLARATION 5 Or`
fn,rya SPECIAL CIRCUIT/MISC
I"
the rebyasoron n.(Sec lamexempHroessa d Professions
Grenx Law for city or -
o county hichre uiresa permiL5,Budnen and Proprove. Code:Any city or- TEMP.METER ORIOLE INS .
camtyw mpflortol perMceac trud,altheaprovgderrsuch,er ttr
any atruduretatemenb that he is alsomquimsuant I the provisions
to pOW,pR DEVICES
rNG' C a actor's statement that he V hooses pursuant it the pm,7030) of the -
3w Cgntradora Licenselaw(Chapter9(commencing with Sgcilon 7000)o(Divi- -
SWIMMING IDOL E1.ECTRI
�OS alon3efthe Busmessand Professions Cods)mthat hebexempttheretromand VALUATION /
y.' tM basis for the alleged exemption. Any violation of Section 7031.5 by anyC� •'Y.�p�y�.r �Qf (Csg (/�
< appilcantfora pr'rMt subjects the applicant to a civil penalty of natmore than OUTT.ETSSWITCHFSFIXTURFS
O five hundred dulls.%W.
❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSDRUCIT
1..7..a compensatlon,wllAothe work,endthe strucwm bnoHntended or offered for
O sale(Esq 7614,Business and Professions Code:The Contradara Lt..Law
j�j�$ does not apply to an owner of property who Wilds orimproves thereon,and OCCCROII[' RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended proffered for sale.IL,however,thebuildingor - TOTAL:
improvement lssold withinoneyearolcompidcon,the owner-budderwlll have
th�rden of proving that he did not build or Improve for purpose of sale.). QTY, .,; ",V PLUMBINGPERMITSFEEL: FLOOD ZONE- APN
"I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 19 �,pa -
contractors to construct the project(Sec.7014,Business and Professions Code: as
The Contractor's Llrenx Law don not apply to an owner of property who 11 '
Wilds or Improve thereco
on, and who ntrads for such pRojeds.with a l ALTER-DRAIN k VENT.WATER(EA) 'tu" a Fu _
FEE SUMMARY
co,Bj(adoKa)limned pursuant to the Contractors License Law, gpCK FLOW PROTECT.DEVICE "ttl 'i'
IJ I am exempt under Sm. B k P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. Z.m SANITARY - .Y_ N
Owner• Date RECEIPTp
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP ,rax SCHOOL TAX Y_ N_
❑I hereby affirm that 1 have o lmurate of coven m spytheore,ora `'s,1 RECEIPT If
3800,UbC.) rkeri Compevatlonlnsurana ora artlfled ropythemot(Sec. GAS.EA.SYSTEM-11NCAOUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT
Policy p GAS EA.SYSrIlM7-0VER d(EA)
Com any � � BUILDING DI VISION Fr.ES
[]PCertilled copy Vhereby furnished. i GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE /-41'r4
F-1Certified copy b flied with the city Inspection division, f
CERTIFICATE OF EXEMPTION FROM WORKERS' _ GREASE TRAP PAID �C O
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20 WE Da[e n,0 t# r
(This section need oat be completed If the permit is torpor'hundred dollar
($100)odifyth - - WATER HEATER W/VrXT/ELECTR. ENERGYPEE Y
]codify that o the person In an the work torwhi cern permit c Ito II he
I shall not employ any Lawn In any manner x ss to become subject to the WATER SYSTEM/TREATING —
WorkernCompensation lasvaofCaliionto.Date PAID L�a�
0 2 Applicant NEW RESIDENTIAL PLMB. SQFT, - Date Cel t# ��
_Z O NOTICE TO APPLICANT.If,after making t his Certificate of Exemption,you
should become subject to the Workers Compensation provisions of the Labor - TOTAL:
F N Code,you moat forthwith comply with such provisions or this permR shall he
W > deemed revoked. BUILDING
CONSTRUCTION LENDING AGENCY • SEISMIC FEE LO
M Ihembyaffirmthat there is a construction lendingagency forthe perform,
ELECTRIC FEE
7 Z ante of the work for which this permit is issued(Sec.3897,Civ.C.) _ TOTAL: V5-0
O 0 Lrodd.Name - '� PLUMBING FEE
LL I— Leodrra Addme QTY. t ' MECHANICAL'PERMIT „'FEE ' MECHANICAL FEE
0 W , I mrtltythat l have read this applicatio...datatethattheaboveinformation
1 incorrect.I agreeto comply with act city and county ordinances and date laws PERMIT ISSUANCE �� FEES PAID:"
} relatingtobulldingmnstmRlon,and herebyauthorlu erpresentativesofthb
cit to entero n the above-mentioned.propertyfor Inspection purposes, ALTER OR ADD TO MECH.
~2 y upon purpu Date Receipt#
�-_ (We)agree to save,Indemnify an d keep harmless;the City of Cupertino
against liabilities,pdgments,codas. Ich may In any way acwe ALR 7ipNDWNC UNIT(TO 10,0)0 CFM) SUBTOTAL:
agalvbal In conesque the gran�tin�g�o(t eperm�it� p� AIR HANDLING UNIT(OVER 10,030 CrM) CONSTRUCTION TAX
'
51go5tore of APE l rat/Contractor Dat IX}1AUST HOOD(W/DIK:T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
WTM eapphrartorfuture building occupant Morenr handle h.rdous HEATING UNIT(TO 100,000 BTU) Date Recel t#
reterJal an def nes by the Cupertino Municipal Code,Chapter 9.P 2,and the
tfcai(h and Safety Cade Secoon 75532(a)t HEATING UNIT(OVER 100,0000TU) ,TOTAL: `CZ�
Yes M No
Will the applicant or town,building occupant use equipment ordevlcns VENTILATION FAN(SINGLE RFSID) Is5Sqryl�qI(UA�N�CE DATE
whlcheM.n.grooueairrict? an.as de0ned by the Bay AreC Air ��"sW
Quality Mavgr'ment DlsMci7 BOILER-COMP(3H1'OR lOap(q BTU) • "•sraBYgla ,
4 Yes No
have read the haza pus noostiabregWrements under Chapter 6.95 of BOILER-COMP(OVER100,000BTI1) 111 O2 p
the Culif.,niCllealthkSafetyCode,Sediov25W ✓V5,25533and25534.I j„JQ[R�
understand that lithe building does not currently have.tenant,that it b my NEW RESIDENTIAL MECIL SQ.FT. - -
respossibility to not By,the occo pant of the uircmenis which must be and -
priar co Certificat cu Panty. A'
uer mthociu gent ate O - ISSUED BY: _`^✓ u,' -
TOTAL:
OFFICE COPY