20844 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bored ing Address: 20844
Zo-3S 51 V�-nom G2 - �Ll1D-
�wAn,Ie�rsq�am�e: ane. -
M••tUCnCh�I.tV �N�rd9'-' CITY OF CUPERTINO-BUILDING DIVISION
co�nsh�ad°:�•/"a�n,e°//�', Lir."°: APPLICATION /PERMIT
•—`G`^-`•?P^'c�Y BMDING-ELECTMCAT rLUMBING-ME LAICAL CAT RY CONTROL ��
�. Architect/Regineer. Llc,No:
ron
• - "
(p6g !.4114 1 QIY ELECTRIC PERMTT.' FEE BUILDING PERMIT INFO
Address: ' PFRMITISSUANCE
KENS D CONTRACTOR'S UE RATION
I hereby affirmthat l am llemse!under provisions of Chapter 9(rommenc APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Sedion7 )ofDivisim3afthe Rusinemand ProfessionsCod,andmy
license Is In fun lua and effM. PANELS
Licen Class ILIc.M Z T
Date�1 O Cmunnetm. Vyx
ARCHITECTS DECLARATION 201-1000 AMPS
02 lundernand myplarushallbemead aspublieremrda OVERIMAMPS SQ.Fr.FLOOR AREA f/SQ.FT.
Fi U Licensed Professional . - SIGNS ELECTRICAL
<� LB'3 OWNER-BUILDER DECLARATION 3 SPECIALCIRCUIT/MISC s�
I herebyaflmothst l am exemptfrom the Contractor's License Law for the
OZ— following on.r.Civello.7071S,Business and Professions Code:Any city or TEMP METQtOR
KEIg mantywhichrequUsaper twmm=&,allenlmpmv,dennlbh,orrepalr
aoystmcture priortoits Issuance,also require•the applicant forsuch permit to POWER DEVICES
ale a signed statement that he is licensed pursuant to the provisime,of the
Contractor's License law(Chapter9(commencing with Section 7000 of Diel.
Sion 3 of the Ousiness end Pro.slmu Code)or that he b exempt lhcrefmm.ed SWIMMING POOL ELECTRI VALUATION
�'•77 the basis for the alleged exemption. Any violation of Sedkm 7071.5 by any 1 OUTLETSSWITCHES FED URFS —L/ 5 -"3101
Z /� O�
�a
applicant for a permit subjects the applicant too civil penaltyof net morethan I V C
$ five hundred dollars($500). NEW RESIDENTIAL ELFOTR
�n
F1 1,as owner of the property,or my employees with wages as their sole `"Q''IT.
STORIES TYPE CONSTRUCTION
compensation,wlllelothe work,andthe structure is not intended or offered for
0 sele(See.7044,Buiino..and Professions Code:The Contractor's Llmrae law
does not apply to an owner of property who builds or improves thermR and
CC:: who doessuchwork himself orthrough hisown employees,provided that such OCC.GROUP RFS.UNITS�1�
Improvements are not intended oroffered for ale.If,however,lhebuilding or TOTA J .CO
pmvement0aaldwithinoneyearofcompIMl Ntheowner-bu0derwillhave
m;�urdenofpmWngthathedidnm Willorimpmvemrpurpascof.a .I. QTY. PLUMBING PERMIT FEE HgODZONE APN
lJ I,as owner of the property,am exclusively contracting with licensed PETIT ISSUANCE a'I
contractors to construct the ponied(See.7044,Bu.lne®and Professions Code: 4
The Contrsctors License Law dare not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffNN
Wilds or Improves thereon,and who contracts for such pwjttb with a
c�Nr�dor(s)Rased pursuant to the Contractors License Law. FEE SUMMARY
I_f I am exempt under Sm B&P C for this reason BACK FLOW PROTECT.DEVICE.
OUTSIDE FEES
Owner re ova DRAINS FLOOR ROOF,AREA.GOND. SANITARY Y N
UaL RFOm'T'p
WORKMAN COMPENSATION DECLARATION FIX'IVRESPERTRAP ,eyt SCI IDOL TAX Y Ncert _
❑1 hereby affirm that I have o ce aware of consent to opytnsu s•iJ RECEIPTM
380 i,abte ofWorken'Compewalion lruurance oracertl(led copy thereof(Sec. GAS EA.SYSFFM-1INC4OUTLETS
3800,lois C.) PARK FFR Y_ N
Policy M RKHWIPT X
Com any CAS EA.SYSTFM-OVER4(EA) BUI LDING DIVISION FE ES
Certifihereby ed copy is filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ed
❑Certified copy is flied with the city Inspection division.
CERTIFICATEMENS PAID LTIPTION FROM WORKERS' CRFASETRAP /9- S3
COMPENSATION INSURANCE SEWER-SAM.L.ARY-STORM FA moFl. Date Recti t# s
(fhbsectlon need not M completed i(the permit V(crone hundred dollars
(S1 W)or les•.) ( WATER HEn.I.FR W/VEM/ELECTR ENERGY FEE Y - N
Icertl(y that In the performance of the work for which this permit is leaved, tQ5 f'r evkl
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Coerpensation Lawcaf California.Dale PAID
O Z Applicant Date Recei I#
Z G NOTICETO APPLICANT.It,after making thisCerUfiate of ExcmptioW'n,you "ERESIDENTIAL PLMB. SQTr. _
should become subject to the Workers'Comperuat loll provbloro of the Labor TOTAL:
In Code,you most forthwith comply with such provisions or this permit shall be _R.4L[LDING FEE
> deemed revoked.
LU
C r CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there e a mrotrudion lending agency for the perform ELECTRIC FEE
0 anceofthe work forwhlchlhbpermit LsIssued(Sec.3097,Civ,C.) TOTAL:
U _ lenders N.me PLUMBING FEE 2(q�
LL F Iender.Aaareas QTY. MECHANICAL PERMIT FEE MECHANICAL PEE a40
O W l certllythatlhavereadthu.ppliattmand statethattheabovelnformatlon
1 [scormd.I dgreeto comply with all dtyand countyordinances and slatelaws PFRMITISSUANCE FEES PAID:
} W relatingt.Wildingmnslrudian,and herebyauthodze representatives ofthl.
(— city loenterupon the above�merbned property for bupMion purposes. ALTFRORADDTOMECH,
Z
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,Judgment,"sand expenses which may In any wayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said C ty In consequence of the gra ring of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX _
Signature of Applican/Contractor /Dale — EXHAUST II00D(W/DUCq CONSTRUCTION TAX PAID:
HAZA R DOLS MATERIALS DISCLOSURE
Will the applicam or future Wilding onv pant store or hand lc harardous HEATING UNIT(TO 100,000 BTU) —91—C2) Date Recei !#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the �j f.
He Ith and Safety Cod&,Wcllon 25532(a)7 HEATING UNIT(OVER 100,000 TIM y 'p OTAL:
❑Yes o
Will the a pplimet or futum bu dding occupant use equipment or d evlces VENIILATION FAN(SINGLE READ)
which emit hxvardc us air contaminants as defined by the Bay Arca Air (°�
Qua lily Mana gement District 7 BOILER-COMP OFR'OR 100,0(0 BTM /.
Yea 40N. �y
have read theF ocutsmaterlals requircmentsunder Chapter6.95of BOILER-COMP(OVIR100,000BTU) �� n{1•itDf'•rlr�
the Callimed.I lealth&SafyCode,Sections 25505,25533 and 25534.1 rhl
understand that lithe building does not currently have a tenant,that it limy NEW RFSIDE"ALMECH. SQ.FF.
r sponsibllitytonaifytheocapantofthe requirementswblch mustbemet _
prior to issuance f Cedlficate a(Occupancy.
ner or authorised age Date ISSUED BY:
TOTAL: CD
OFFICE COPY