20450 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra en Id-11Hcalian ///^^^ PERMIT NO.
Building Address: 2 7 �� ^ ��� a ( 20450 O 4 C O
aft &0CT&V; 796' �o o CITY OF CUPERTINO-BUILDING DIVISION J
`• Coetactors Name: Lie.No: APPLICATION I PERMIT J J
BUfLDINGF3.ECTRICALPLUMBINGMFOIIAMCAL CATECARY CONTROL tl'
Area / yJ ' Tom' �/ �p•�p2"�aL��� / QTY ELECTRICPERMIT FEE BUILDING PERMIT IN
Add.:100 1� '(�L�I.L. µ.� PEIWTISSUANCE ® hl,�l PLUMB
� ❑ ❑
5W e:1lS ICENSEDCONTRACFOR'SOECLARATION
I hereby affirm that l am lkemadi under provisions of Chapter9(mmmurc- APPLIANCES RESIDENTIAL JOB DESCRIPTION
incense I In full 7000).1d affecn3otthegusinesaandlara(nslone Code,and my
license IsInforce andd(ect. PANELS �
License Clam Lontr '`T '—^^"•�-�„
Dale Contractor
ARCHITECTS DECLARATION 70140AMM I
rcz I understand my plans@hall be used as public records. OVER1000AMIS \ ham) SQ.FT.FLOOR AREA S/SQ.FT,
O
q O (
Licensed Professional SIGNS ELECTRICAL i
OWNER-BUILDER DECLARATION It`•
t`n BS SPDCIALCIRCU[T/M
t" 7 1herebyeflmn that l am exempt fromthe Contractors License Law for the \ s\N
Z O following reason.(Section 7031.5,Business and Professions Code:Any city or
Fz TEMP.METI POLEINST. '
county which rcqulrcaa perMttorons[md,alley lmprovmd1f such,ar repair /
a nysimmmprlortoltsawancgal mquimstheapple' for=h';rMtto WER DEVICES ,/
c. file a signed statement that he h licensed pursuant to the Provisions of the
3u, Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- \ M I
01 alon3 ofthe Business and ProfeeeionsCode)orthat he b exempt therefromand MING IDOL ELE C IS � VALUATION
y.'S the basis for the alleged exemption. Any violation of Section 70115 by any C'� \a ,yy.r;_
{gj 05 tforaperMbub)cctstheappRcanttoocivilpealtyofootmarelhan
ppRanO .EIS�N7TCF{FS �/OOU /1''
E !Lry"Aundred dollars($500). .I
R IDENDtL El, 7
�I
as owner of the m SOd'T STORIES 7TPECONSIRUCTION
property,or my employee with wages r their sole
m&c.7044,wllldotMworkand the s Code: Vnet Intended ar..Loffered(or
O
.1.&c.apply
Ifito ino neer of proProfessiperty
Code:The Contactors Linens law
$ does not apply torn himself
otprough who nampuilds oyans,p Wvdth that
OCC.GROUP RES.UNITS
who does
side amrnot IntendedorougM1 d ow formic.
If, onveprovidedthat gor
Improvementsarenot Intended earotrdtarsal@.the ower-bilder, iii have TOTAL:
Improvement Vsold within oayearafmmpldion,theowner-bullderwill have
UtLtIuMen of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
j_j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7014v Business and Professions Code:
The Conte ctor's License Law does not apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
Wilds or Improve@ thereon,and who mnteme - -for such ptojects with a FEE SUMMARY
tr0)It...d pursuant to the Contractor's License Law.
c am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE OUT.SIDE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY . Y N_•
Owner Date Rptlppp
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm,that I have a artlFlute of consent to self-Insure,ore RECEIPT#_
certificate ofWorkeai Compensationlnsurance or a certified copy thrmxxf(See. GAS EA.SYSTEM-1 WC4 OUTLETS PARK FEE Y N
3800,Lab C.) RECEB'I N
Co X GAS EA.SYSTEM-OVER4(EA)
Com ray BUILDING DIVISION FEES
�Carified copy is herebyfamished.the cid.sit
CRCASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE $S
[ Certified mpy is filed herebyifamis dry inspection division. 965
CERTIFICATE OF EXEM"HON FROM WOR KERS' CREASETRM PAIDSZ U Zsf'9S
COMPENSATIONINSURANCE SEWER SANITARY STORM EA 7001x1' [e Recei t#
(Thlssection need eat W complat d Bthe permit fi(orons hundrad dollars
($10000rlass.) WATER FIEATER w/VENT/F7.FOTR ENERGY FEE Y N
I mnifythat in the performance of the work forwhich this permit is Issued,
I shall not employ any person in any manner so as m•yerome aubjM to the WATER SYSTEM/TREATING
Workea'Compyw{yeglswlr 9�I Caylf laa„Ba[e 5 '2'f�'�u PAID
icant
Z Z NOTICE TO APPLLICCAANTT::lf,afte J� ,Ce,Cerlfflrate of Em NEW RESIDENTIAL PLMB. SQ.Ff. Date R 1 [#
P
2 should be..subFd la the Worker@'Compensation provisions of the Labor - TO L:
= N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING
LU G deemed revoked.
d CONSTRUCTION LENDING AGENCY SEISMIC FEEA IU
s
I hereby afflrmtbut there Is a construction lending agency for the perform- ELECTRIC FE,
O ante ofthe workfor which this permit iiyy sity�(Sec.3097,Civ.C.) TOTAL:
U Lender@ N. A} / A' PLUMBING PB
iL H Lander'.Addass Q1'Y, MECHANICAL PERMIT..:-/ FEE
OW I certifythat l have read thisapplicationand statethatthe above information MECHANICAL •'E
1 iscorrect.Idgreeto complywith all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
r fA relating tobulldi constroctton,and hereby authorize representativesoflhis -
F Z city mentor upo he above nllond property for Inspection purposes. ALTPJi OR ADD TO MFLFI. Date Recei I#
— (Ws)agree t ve,Inde Ity an d keep harmless the City of Cupertino p
ago lnstilabi dgmeet els and expenses which may in any wayaccme AIR FIANDIJNG UNIT(TO 10,000 CFM) SUBTOTAL:
agalnsis t 1 ro sequ ofthe granting of this permit.
7 LU AIR HANDLING UNIT(OVER 10,0WCFM, CONSTRUCTION TAX
Sigwmm of Ap rat/ on aA
ctor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defect by the CypeAt Munlet I Code,Chapter 9.17,and the
Hcallh and Safety Cotle,$eftion 25537(0)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
nYes (�No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSL fITE
which emit haeadous air contamiants as deflnd by the Bay Area Air �1s�'
Quality Management D�ialrss<<7 BOILER-COMP C311P OR 100,(X10 BTU) a3
4 Yes Zoe (w u
s, haa
ua materials requirements under Chapter 6.95 of BOILE)!-COMP(OVIR 100.000 BTU) JUL a}
the GlSof Cds Sedions75505,2533 and 75534. 1 _ �1
undersulldi doeanot cum,,ifiyhave atenanq thatItis my NEW RESIDENTIAL MECH. SQ.FT.
resp0ahen panto(the requirements which must be metprior torlifica of Occupancy.
Owner or aulhmrl •d agent Date
TOTAL: ISSUED 6Y:� jkra
OFFICE COPY
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