20865 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
11.1hrihng Ponied Identification PE MITNO.
Buading Addree &6c 9 - 20865
versante: - one: A
CITY OF CUPERTINO-BUILDING DIVISION
Caanctar's ante: ue.No: APPLICATION / PERMIT
N U BU LDINGELFLIR CALPLUMBINGMECf AMCAL CATEGORY CONTROL v�`� Q
Architect/ g(neer. LIe.No: 1D SOS
sono -k QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Aaareaa:l l3'1 Scan J Ylry PBRhIITISSUANCE 12,0(:
LICENSED CONTRACTOR'S Dt LAR N
I hereby a(f4m that licenced underprovislona hapter9(comneme- APPEANCFSRESIDENTIAL 4�J JOB FSCRII'RON
Inansc isectullfor0andelslon3oflhe BuslncssandP eulonsCode,andmy, R�sra�uk�vr
license le Ins force and c.# PANES �'I'' "La
License Chm Lien I l�a
Date CoMnctor '
ARCHITECTS DECLARATION 201-1000
NO Z I understand my plana shall be used u public records. OVER 1 W0 SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS TRI
OWNERexampt from
DECLARATION SPP.CIAL /M
OR3 nwing rssermthatLmexempt(ro ossa Contractors License Lw for the
Kgto qqqq l ntynhichre.(SMion7 tto Business and Pimp bnsemie hny cityo
� mantywhlchrequlrtsapermittoconstruct,atter,Improve,demolish,orrepalr TEMP.M R [NST.
aoystruclum pdarto its Issuance,also requirestheappliant forsuch permit to FO
file a signed statement that he is licensed pursuant to the provisions of the
OroI- Contractor's License Law(Chapter 9(commencing with Section MM)of Divi-
don of theBudnesaand PrefesslonsCode)orthat he b VALUATION exempt therefrom and G LEL RIC
the basis for the alleged exemption. Any violation of Section 7031.5 by anyO E [,IFS 'JI s Q1 ' tV Q
applicant fora permit subjects the applicant to a civil penalty of not more than
44+11
live hundred dollars($500).
7< ❑I,as owner of the property, W R �� STOWIS TYPECONSTRUCTION
p party,car he employees with wagon as their sole
.1a(Se
compensation,Rudeness
awilletothe workandthestCde: isnot Wended carofferedfor
O sale(Sec. pply to alnowarfnd property
Code:The Contractor's License Law
does not apply to an owner o!property who n builds or improves thereory and OCC.GROUP RES.UNITS
whodoements am nothimselfdedoroagh hlsowneroffered .If,however,
o es,providpraise uilding or thatsuch - 'b /t
impowemenlsarcd within dneyearfcompletionthe wee builderwill have ' TOTAL: _b
Improvemant bwld within oneyearofcomplabrythe owner-bulldawillisave
t en of proving that he did not build or improve for purpose of sale.). QTY. PLUMB GP MIT FEE FT.00D ZONE APN
ate owner of the property,am exclusively contracting with licensed
tnctos to construct the project(Sec.7044,Business,and Profenons iCode: PERMIT ISSUANCE 11100
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(FA)
Wilds or Improves thereon,and who contracts for such pkajects with a 1zx CIO
gp(�actor(s)licensed pursuant to the Contractor's License Law, FEESUMMARY
c LJ I am,exempt under Sec B&P C for thb.reason BACK FLOW PROTECT,DEVICE
OUTS I IM]IF
DRAINS FLOOR ROOF,ARE A,GOND. SANITARY Y a N
Owner Date RECEIPT s
WORKMAN COMPINSATION DECLARATION FIXTURES.PER TRAP 1� SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-lore,w a ��.
cenifimteo(Workers'Comperaationlmuwmoramrtified copythereaHSce. GAS EA SYSfEMt WC/OUTLM PARK PER Y N
3800,lab C.) �('.(�
Policy 0 RECEIPT M
Cam any - CAS EA,SYS-M-OVER4(EA) BUILDING DIVISION FEES
Certified copy b herebyth the cid. RFASE/INDUSTRL WASTE INTERCEPTOR 11 PLANCHECKFEE
❑Certified copy la filed with the city Inspection division. _`sem
CERTIFICATE OF EXEMPTION FROM WORKERS' AFASE TRAP PAID' '7
COMPENSATIONac. d,dift apaR ti fo SEWER.SAMTARY-STORM FA.200FT. Date Recei t# /.
(I'hlssMlan need not be completed If the permit Is(wore hundred dollars
($10B)arlesa) WATER HEATER W/VENT/ELECTR pp ENERGY FEE Y N
I certifythat In the performance ofthe work forwhich this permit le blued, Ze —
I shall not employ any person in any manner so n to become subject to the
Workers'Compensatlon Laws of California.Date WATEt SYSTEM/TREATING PAID. {�
0 Z Applicant NEW RESIDENTIAL PLMB. SQFL Date Rewi t# BOte>a
Z O NOTICE TO APPLICANT:If,after nu king this Certl(lale of Exemption,you
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL: Z sZ
N Code,you must forthwith comply with such provisions or this permit shall be
LUj deemed revoked. -BUILDING t
CONSTRUCTION LENDING AGENCY SEISMIC FEE ,OO
1 O IherebyaWrm that there b a construction lending agency for the perform ELECTRIC FEE u�
V O Lnder Namerkfor which this permit b issued(Sec.3097,Civ,CJ TOTAL '1 PLUMBING FEE
LL 1— T.odre.nddreas QTY. MECHANICAL PERMIT J FEE. MECHANICAL FEE ( tl
O W Icenav
ifythatlhereacitheappliawov
tlonandaethattheabelnformatlw 4
iscomed.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE 172,CO FEES PAID:
S
} misting to building constmctio,and hereby authorlee representatives of this // ^s
f U) city to enter upon the abovcmentiaried property for inspection purposes, tp ALTFRORADDTOMFLH, 1 on Date ReCCI f#
E (We)a to save,End ema]y an d keep harmless the City of Cupertino P
against Ma Ries,,jodg me=tsandex s which may In anyway accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against sa Ity n ce of tis in of thio permit.
,Sq /0O AIR HANDLING UNIT(OVER 10,°00CFM) - CONSTRUCTION TAX
Signs reof Applicant/ ono-actor Date /r D(}IAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATE AL UISCLO URE
Will the applicant w future WRdl and store or adlehavrdous HEATING UNIT(TO 100,000 BTU)
materlalasdeRned bythe Cupertino oras pal CodgC Ater 9.1Z.rultha Date Reeei tit eT
Health and Safety Code Section 2(a)7 HEATING UNIT 100,000 BTU) TOT L: ! s
❑Yes No _
Wiiltheapplicant ortumre Wild ng occupant use equipment or devices 2 VENTILATION FAN(SINGLE RESID) v� . ISSUA}JCLz• A E
which eMan a seems air contaminants as dented by the Bay Arca Air - .
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU) 1 1990
Yea n❑No NOVY W I 1 v
haverleap&he ardfet Code,bregW25505, 5813 and 25534.
of BOILER-COMP(OVER 100,000 BTU)
the erstCaliforniaia t if tth&Safety Code, otl Ions 2550.5,have
a t sad 25534.I
understand thatihhebulldingdon solcorrcntlyhaveatenangthat itismy NEW RESIDENTIAL MCCH. SQFf. IPE A`"'rt01'I%r'fp
resporebility m notify the occupant of the req timments which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorised agent Data ISSUED BY:
TOTAL: s�
OFFICE COPY