20540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect identification PERMITNO.
Building Address: "1 onAt W � - 20540
v CITY OF CUPERTINO-BUILDING DIVISION n
C mi or'.NNail' n uep ' APPLICATION / PERMIT
Arc /En r. b BUILDING-ELECnUCAL-PLUMBINGMECHAMCAL CATEGORY CONTRO
-1' IEpf A Ic.fJo:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - y I ' El LICENSED CONTRA PLUMB MECH
OR'S DECLARATION
I hereby affirmthat l am licensed under provblona of Chapter 9(commenc APPLIANCESRESIDENTTAT. JOB DESCAII'170N
ingwlth Sedion7000)o(Dlvielon3ofthe Buslne andProfeaslonaCadgand my
I is In(uB and effect. PANELS
Licen 1 Lk.p 'I V
Date tl Contractor
ARCHITECT TIT 281-1000 AMPS
q�q�uu000C Iundemtandmy.piaDnT'ghaBbeyµ�(a�Ob�recordy OVERIOOO AMPS SQ.FF.FLOOR AREA S/9Q.FI'.
6i Llcenxd Pro(esalms "" fYI SIGNSELECTRIGL - r-� OSS
<< LG7 OWNER-BUILDER DECLARATION *VfJ-7
IT/M15C v
Z,�4 I herebyafflrenthai l am exempt from the Cmame orb Llren.Law for the
p following reason.(Sedlon7031.5,Business and Profesom.Code:Any city or TEMRPOLE ST.
Fri"' muntywhkhrequimsapermittomratrod,alter,lmpmve,demolbh,orrepalr -
g anystmdure pdortoltsiswance,aleorequlmstheappllrant for such permit to S
t9 r�G flie a elgned statement that he b Beemed Pursuant to the provisions of the '
3r` GO trader's License Law(Chapter 9(commencing with Section 7000)o(Divl- _
elon3o(Ihe Bueinnsand Profeas(oru Code)mthat he is exempt therefromand OL VALUATION
-
J� doos
the bash for the all eged exemption. Any Wolatlon of Sectkn 70315 by any t applicant fora Permit subjects the applicant toa civil penalty of not moretionred dollsLs ownero(the properly,or rtry employees with wages as(heir sole '� STORIES TYPE CONSTRUCTION
mpensatio ,will dothe work andthe stmdurc lariat intended or offered for
sale(Sec.7044,Business and Professions Code:The Contractors License Law
not apply to an owner of property who builds or Improves therem,and
whe doe wchworkhimxl(orthreughhiaownemployeespmvidedlhatwch �• DCC.GROUP RES.UNITS
mprovements are not Intended oroffered forsale.If,however,thebullding or TOTAL: 1tJi�
O, Improvement Lcaoldwithinoneyearofcampidlon,lheowner-bullderwiilhave 'J
tls*rden of proving that he did not build or improve for purpose of sale.), QTy, PLUMBING PERMIT FEE ,Ffpp z NNg pPN
U u L as owner of the property,am exclusively contracting with licensed con
/ contractors to construct the project(Sec.7644,Business and Professions Code: PERMITISSUANCE
The Contractors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such planjeds with a ALTER-DRAIN&VENT-WATER OW
t actor(eI licensed pursuant to the Contractors Lirenx Law. FEE SUMMARY
j 5I am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE
Ow ar Date DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N_
WORIUNAN COMPLIVSATION DECLARATION - RECEIPT#
QT hereby affirm that I have a certificate of consent to self-insure,or FIXTURES PER TRAP SCHOOL TAX Y N
rertl(iate o(Worken'Comperwtlonlrauranre ora rerti(kd mpythereof(Sec. -
RECEIPT
3 00,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE y_ N
Comryany GAS EA.SYSTEM-0VER 4(EA) BUILRECEIPTI VISION FEES
ECertified copy is hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified
copy b(fled with the city Inspection division. rj x
CERTIFICATE OF IlKEMPFION FROM WORKERS' - GREASE7RAP 'OPAID ls�`
COMPENSATION INSURANCE '
(Thissection need not be completed if the permit b(crone hundred dollars SEWER-SANITARY-SIORM EA.20067. Date Recei t#
csl Iartifexa WATER FLFATE[t w/vENT/ELFCTR . ENERGY FEE Y N O p
Icertl(ythat In the per(omanre of the work forwNch apennitlsiswed, r
Z I shall not�BpIOY Y Pere a4,(man r so u to b co sob'dalo the J
Workers, a'I U — wp'>�sys`TEM/TREr+nNG PAID
NOLICEIV e Date Recei t#
ZO NOTICEcomPPLICt to
orlmaking eis Exemption,You NEW RESIDENTIAL PLMB. SQFC. -
Code,shoulbecome subject the Work era'Comsuch pruasonporthis s of permit
s Labor TOTAL: • Z
W� N Code,you=at forthwith comply with such provisions or this permit shall be
> cimmedrcvoked. - UJ DI E 3 00
n c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hfthew Rrmthal there lsemretmctlon lending agenry fmtheperloim ELECTRIC FEE x(�
0 ante of the work for which this permit is iswed(Sec.3097,Clv.C.) TOTAL:
fJ _ Lender's Name - PLUMBING FEE
LL F Lenders Addneas - QTY, MECHANICAL PERMIT FEE - MECHANICAL FEE ,00
O W .Icertlfylhatl have rcadthle eppllatlonand statethatthe above Information
C iscodxd.I agree tocomply withal)city and county ordinances and gate laws T-
IL ISSUANCE (-),CD FEES PAID:
} N relating to building construction,and hereby authodee representatives of this �s�
I— Z city to enter uponthe above-mentioned property for Inspection purposes. JAIR
ORADDTOMECIL
V (We)agree to save,Indemnify an d keep harmless the City of Cu pertine Date Receipt#
alnatIt s:i ties,p gmenb,costs and expenses which may In anywayaccrueANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a tsai City Inco ence oft granting of fhb permit.
ANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appuan/Contra�.� Dare UST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS TM EE RIALS DISCLOSUREWllltheappllantorfuture building oavpant store or handle haeardousNG UNIT(TO 100,000 BTU) Date Retei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
6lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTUs a
r-1Yes N No TOTAL
Will theappllant orfdurebuilding occupant useequlpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousmi
air contanants..defined by the Bay Area Air
li.y Management DuMct7 " BOILER-COMP pI-B'OR 100,008 8TU1
;Yea 11��No 1
have read the hauroue materiab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,D06 BTU))
the Call(ornla He lth&'Safely ode,Sedloro 75505,25533 and 25534.[
u nderstand shat the bulldin cea not currently have#tenant that itis my NEW RESIDENTIAL MGCH. �,FT. t. ^t:. ri
a Pty to Miry the oc rt oft uiremenb wKlch must be met ti � QIP Cry '
WW10y,Of
' prio uance Certl(i fOccu a ry. '. V
Own authorized agent Date ISSUEDBY: w'^'W~
OFFICE COPY