20869 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project tdemlflcationPERMIT NO.
Building Address: sP a�0.� 20869
none came: one. q
midslc �A GQn CITY OF CUPERTINO-BUILDING DIVISION ryo
Contractor's Name: LIc.No: APPLICATION / PERMIT
BUILDINC-ELECTRICAL PLUMBING-MECHAMCAL CATEGORY CONTROL If
AmV; /Engineer. LIc.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 1'1 ❑ ��, ❑
_y/LLI E!N!ED nACAR PERhOTISSUANCE
LICENSEDCONTRA Or pr DWI,LARAIONS Lis
11
I hereby
actionrmthat l am Beentaxi usinemandP fe Chat C(commm APPUANCFSRESIDEN7IAL JOB DFSCRII'IION
Ingwith In full
oftheBuslnevandProfeselonsCode,and my
Leoneisln full force end c.If - PANELS
License Cbv_ LicM 15Qy9y1 �^+ '
Date Contractor /
ARCHITECTS DECLARATION 201-1000 AMPS
Z I understand my plans shall he used as public records, OVER I(00 AMPS SQ.FI'.FLOOR AREA
wwO
O Licensed Professional SIGNS ELECTRICAL V
Qns OWNER-BUILDER DECLARATION
In Fn SPECIAL CIItCNT/MISC
t, y owingraf@mthatlam31.5,Business fromthe CoinractoriLlrense Law fee city or
7p 9 F� following reason.(Scttio e7 t to, tmc and Aofevlons emlCode: ,y city or TEMP.METER ORIOLE INST.
y xnystm=ntym requbvaperMtto construct,alter, apmvent for
ch,orrepair
any structure priortostatement
Its that
he is aUo sed pursuant t the (onuions of it a POWER DEVICES
K V file a signed statement that M V licensed pursuant it the previsions of the
3�
Contractor's License Law(Chapter9(mmmenWgwlthSection 7000)of Diel. SWIMMING BOOL ELECTRIC
Off' slan3oftheeuslnessand ProfesslonsCode)orthat hetaemse therefmmand VALUATION
the basis for the alleged exemption. Any violation of Sections 7MIS by any OUTLETS-SWITCHES-FIXTURES lc
rrNOilapplicant permit subjteathe applicant to a civil penalty of not mom than VJ
$�e five hundred dollars(1.500). NEW RESIDENTIAL ELECTR RT.
7 ❑T,as owner of the property,or my employees with wages as their sole STOW TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
O .In(Sc.70K Business and Prefessioru Code:The Contractors License law
(j $ docs not a pply to an owner of property he builds or improves thereon,and C GROUP RES UNITS
whodocssuchworkhlmselforthtough hisownemployees,provided that such p�
Improvements are not Intended oroffered forsale.If,however thebuilding or TOTAL: 4
Improvement Issold withinoneyearofcompldion,theowner-bullderwlll have
tis Mcnof pmv)ng that he dad or improve for purpose of ule.). QTY. PLUMBING PERMIT FEE
� mm bun
I,as owner of the property,am exclusively contra Ting with licensed PERMIT
ZONE APN
PERMITISSUANCE
contractors to construct the pmject(Sec.7004,Business and Professions Cade:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pmjmts with a
c7nipe ons)licensed pursuant to the Contractors License Law. FEE SUMMARY
LI I am exempt under Sec. rea
B&P C for this son BACK FLOW PROTECT.DEVICE
DRAINSFIAOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner RECEIPT tl
WORKMAN COMPENSATION DECLARATION FD(TURFS PER TRAP SCHOOL 7A% Y_ N_
❑1 hereby affirm that I have a certlBate of consent to self-Insure,ora RECEIPT 8
ccrtifinteufWorken'Compensation huuarceora certified copy thereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE YN
3800,Lab C.)
— RECE'T tl
policy tl GAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
Cam any
ECenlfled copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF PREM PTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM E.A.20011. DatC RCCeI 1#
(this section need not he completed If the permit it for one hundred dollars
(SI(0)orless.) WATER HEATER W/VENT/ELDCTR ENERGYFEE Y_ N—
I certify that In the perfomunce of the work forwhlch this perrrdt is issued,
I shall not employ any person In any manner so a to become subject to the WATIR SYg.IEM/TREATING
worker:Compensation Lawsof California.Data PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQFI. Date Recei t#
Z O NOTICE TO APPLICANT:If,after ma king this Certlfialeof Excoriates,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall he 'BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirmthat there is a construction lendingagenry,forthe perform TOTAL: ELECTRIC FEE
dLCA
M Z arm of the work for which this permit is Issued(Sec.3097,Civ.G) PLUMBING FEE
V O Lener's Name
LL leader.Address QTY.j MECHANICAL PERMIT FEE MECHANICAL FEE
ImdlfythatI havere.dthbapplimtlonandstatethattheabmelnformatlon
O W
1 Iscorrect.l agreeto complywith alleityand ecuntyordlnanms and nate laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby aulhodu representatives of this
F city to enter upon the above-nsendaned property for inspection pu,p.. ALTER ORADDTO MECH. Date RCeefp[#
? (We)agree to save,indemnify an d keep harmless the City of Cu pen Ino
V against liabilities,.dilettante,.#.and expenses which may,In any wayacnue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against utd tymconseque of a graining of this permit' CONSTRUCTION TAX
AIR HANDLING UNCI(OVER 10,000CFM)
grw art/Coatra o to Ex UST HOOD IW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURO
Will the applicant or future building ocnupant store or handle haaardow HEATING UNIT(TO 100,(1(10 BTT) Date ReceI t#
rwterlal as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyCede Sectlon75537(a)7 HEATING UNIT(OVER 100,000 BTN TOTAL: a
❑Yea No
Will the applicant orfutum building occupant use equipment or devices VENDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardous air contaminants as defined by the Bay Arca Air
On a lity Maragen ent District BOILER-COMP Oto'OR 100,0(0 BTU) PAI
^
Yes o M
T have read the boaxedious materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,"STU)
the California Health&SafetyCode,Sections 25505,75533 and 75534. 1 //��
undersmndthat if the building does not curtently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT AUG z; 1990
responsibility to notify the occupant of the reguirvrenls which must W met
prior to is of.Certificatco Atlq�
cIt' ^f^f
nerorautho gent T to TOTAL: ISSUI!DBY:
OFFICE COPY