20928APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
10 20 Bulldi�Pro act Identification y
Rullding Address: Ia, �I�
PFJ WTN20928
/caner• one.
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CITY OF CUPERTTNO-BUILDING DIVISION
I^rr
cj°' o °NAme—LIoNe:
APPLICATION 1 PERMIT
Jp�
Lb C
-/I 1 C 1 aL ✓I
ArcIted/ gI car.en Lk. No:
BUIL.DINGFlECTRICALrL[JMRINGMECHANICAL
CATEGORY
CONTROLM
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
1:1 1:1LICENSED
PERMIT ISSUANCE❑
CONTRACTOR'S DECLARATION.
I heiebydlkmthatlam.1.3.iheBusi emend mCT.pt.r9de,and c
ingwitlium.hSactim,infull 7l100).rd a ffl�n3oftheBueineesandrmteaslonaCode, and my
license is In full erre and dreg.
Lken Class Lk. N
APIPLIANCESRESDENTIAL
JOB DESCRIPTION
(Hoc- TIsaaw1
1
-
PANELS
Date � Contractor
UP TO 2DO ANTS
201.1000 AMPS
ARCHITECTS CIARATION
I understand my plans shag be used as public record a.
OVER 11100 AMPS
SQ. Fr. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Limned Professional
SPECIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the
TEMP.METETORI'OLE INST.
following Mason. (Section 7031.5, Business and Professions Code: Any city or
muntywhlch mquiresa permit tomm cod, alter, Impmve, dennllah, ormpair
anyetrudurepdomtoltdldwance,a Ll.l.uimtheappH.niforsuchper ito
file a signed statement that he is Ikenacd pursuant to the provlsloes of the
POWER DEVICES
SWIMMINGPOOLINECTRIC y
0[TILETSSW[TC EXTURFS
Custractor's License Law BCopter9(commencing with Section 7000) of Divi-
sion 3 of the Business and Prafeabn Code) or that he is exemptlherefrom and
the basis for the alleged exemption. Any violation of Section 7M" by any
applicant fora permit sub)ects the applicant to a civil penalty of not morstlun
/ivy, as undre
ownerdollar
I, as owner sepr.
property, or my employees with wages their dole
VALUATION
NEW RESIDENTIAL SQ.FI'.
STORIES
TYPECONSTRUCTION
'
will ldof d.and the s t Intended r
andhe
.1. IScompeM 70KCodurckn
sok (Sec 7064, Rashness andf Code: The Contact.?orcense Law
theme Law
property or Improve.
does not applywhodoesuch wean owner ofdprough hison ilds emorimproovided that
whodoeseuch work hlmaelorthrough hisown employees, prwidedthat such
OCC. GROUP
RES UMTS
Improvements are not intended oroffered for sale. If, however, the building or
OTAL:
Improvement hsold within oneyearofcompletion, the owner -builder will have
t11LJZu rd en of proving that he did not build or Improve for purpose or sale.).
U I, as owner of the property, am exclusively contracting with H.eneed
contractees to co es the project (See 7014, Buelness and rrdeabm Code:
QTY, PL 1 G MIT FEE
FLOOD TONE
APN
p IT NCE
The Contract./e Limned law does naw apply to an owner of property who
builds or Improves thereon, and who contract° for such pTjecta with a
cq➢1[actor(d) licensed pursuant to Me Contractor'° License Law.
LJ I am exempt under Sec. B h P C for this reawn
ALTER- IN k VFM-WATER (EAI
FEE SUMMARY
BACK W PROTECT. DEVICE
FEES
NS FLOOR ROOF, AREA, CO
SANITARY Y N�
RECEPT N
Owner pate
WORKMAN COMPENSATION DECLARATION
1311 hereby affirm that I have a certificate of consent to self -Imre, ora
cedllcate
FI%TURF_S PER TRAP
SCHOOLTAX Y_ N_
RF N N
GAS EA. SYSTEM -I INC40 S
-CEI
PARK FEE Y N
RECEIPT#
a(Worken'Comperuatlonlnunne ora ertlfkd copy thereo!(Sec.
1800, lab CJ �s.s aI
Y -J"r'1 '
C.
Com any
PCertl(led
on
GAS FA. SYSTEM -0V 4
BUILDING DIVISION FEES
copy amby umam
ryl Certified copy is Bled with the city Impaction division.
GREA$E/WDOSIRL IN
PLANCHECK FEE
GRFASETAA'
CERTIFICATE OF UEMPF10N FROM WORKERS'
PAID
COMPENSATION INSURANCE
ITMn section need not be completed it the permit b (Drone hundrtd dollars
Date Recei t#
SEWER -SANITARY- EA. 200{T.
WATER IILATPRW/VENT/ELECTR
ENERGY FEE Y N
($100) Iotifyth
Icertlfy that In the performance ofthe work forwhlch this Fermat is lowed,
WATER �,�/TREAIING
I shall not employ any person In any manner so u to become subject to the
Workers Compensation Laws of Calltomia. Date
PAID
Appllcant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Worked Compematlon provisions of the Labor
NEW RESIDENTIAL PCMB. SQFI'.
Date Recei t#
TOTAL:
BUILDING
Code, you must forthwith comply with such provision or this permit shall he
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a convection tend Ing agency for the perform
ane ofthe uimkforwhkhthb rmit is Issued (Sec. 3097,Civ.C.)
Lenders Name L
Lend.e.Address
I certltythat l haverea th applcarom and amtethat theabove Information
uommat. I agree to complywith al city and county ordinances and statelaws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE .�
FEES PAID:
relating tobullding construction, and hereby authorize representatives of this
city to enter upon the above,mentloned property for lmp.0t.n purposes.
(We) agree t. save, Indemnity an d keep harmless the City of Cupedlno
agaimt HablBttes,j,dg.en,.d.andexpenseswhlchm.ylnanywayacerue
ALTER OR ADD TO MECH.Date
Receipt#
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
°galmm��y Id City Incof the granting of this permit.
ss�' A�� ' _iG.
AIR HANDLING UNIT (OVER I0,000 CFM)
CONSTRUCTION TAX
Siignatum of Appllcan Contractor Data
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Reoei t#
Wllltheapplicant orfumm building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I lea lth and Safety Code cti.n 25531(.)7
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
❑ Yes No
Willthe zppllnnt taredwilding. pantuaeequlpmentordevims
VENTILATION FAN (SINGLE RESD)
NCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management st 7
Yee No
4havomad lha hlk emode, Sections 255nbund.r Chapter.1 of
the understand
t Health he building
Code, Section 25505, have a tenant, and 25534. I
understand thatn tify the occupant not erequire antswichthat it met
responsibilityfl.rta tondifCelicateofoltherequlmmentswhich must be met
pdor to s anceo Ced Icate ofOccupancy.
1(-16
Owns or auihodzed ag t . Dateate
j"
pp/f77
IsTa70
VS��rJlasw.af �y
ISSUED BY: QC),
BOILER -COMP (311P OR I00,DM BTU)
BOILER-COMP(OVEt100,Ip0 BTU)
NEW RESIDENTIAL MECF 7. SQ.Ff.
'
- eDQ
TOTAL:
OFFICE COPY