20611 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PERMIT NO.
Building Adders.: 20611
/0/0 I.J.S-1 L N +v
F0ams: one: A
T0�1.v /Y1 t�LI+G) I S AS3 81!2 CITY OF CUPERTINO-BUILDING DIVISION
Contract.e.Name: Lie.No: APPLICATION I PERMIT �'— a b ` 9V
ros 'S Lakvab I 81 BUILDING-ELECTRICALPLUMBMGMECHANICAL CATEGORY CONTAOLN
Architect/Engineer. BaN isa ,� -i.No:
7 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE El ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc- AFTUANCFS.RESIDENTIAL JOB DESCRB-1ION
0)
ingwlthSection 70of Christen 3 ofthe Busirssa ind PrefetaansCode,and my
Ilone.Is In fail force end effect PANELS
PF-
License C{a®G- Lie.YI S 6 I f2�p P
Date Contractor O l( UP
ARCHITECT DEC RATIONIODO AMPS
Ob
l understand my plarashall be used as public A. OVERI000AMPS SQ.R.FLOOR AREA g/SQ.IT.
O
Fi Licensed professional SIGNS ELECTRICAL
�<<6 OWNER-BUILDER DECLARATION - SpEC1ALCIRCIRT/M {
Z t.., Ihereby af@mthat l am exempt fromthe Contractor's License Law forth.
O
following reason.(Section 7W 1.5,Business and professions Code:Any city or
y: pDaM R ORPOLE
r� countywhich requires,permittgmnsnrouines thea prove,demsuch,uch orrcpalr
anyatsigned pdementor to that
he Is sicca sed pursuant t the prr isdons of t e [YIWER D
file a signed statement that he is Ilreneed pursuant to the provbba a( the
Contractor.License Law(Chapter 9(mrmuneing with Section 70D)of Divi-
a,�0 alon3 ofthe Buslnessand ProfmionsCode)orlhzt he I.eaemptthercfromand SWB.tMINC VALUATION
I! the beat,for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCFIXTURES
mre
applicant(Ora permit subjecnsthe applicant to a civil penalty of not othan
p)$ five hundred dollars(SM. NEW RESIDENTIE ELECTR SQ.Ff,
lwv7vvv �n ❑1,as owner of the property,or my employee with wages a their sok STORIES 7YpE CONSTRUCTION
compensation,will do the work.and the structure is rot intended or offered for
O role(See,7064,Business and Prufeasions Code:The Contractors Llmae Iaw
r3$ does not apply to an owner of pmperty who builds or Improve themon,and OCC.CROUP RFS.UMTS
who do....chwork hlmaelf orthrough hlsownemployres,providedthatwch
improvements arc not intended oro(fered formic.IL however,thebulldleg or TOTAL:
Improvement b=old withinoneyearofcomplelion,theowner-bullderwilt have
O,j;urdenofpmvingthai he did rot build or improve for purpose ofule.). CITY. PLUMBING PERMIT FEE
L J liceFLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed — PFRMTTISSUANCE I•lx..r\
conuactonto mawct the Lproject(Sec.apply
to
and Iof pro ga Code: << W
The Contractor's o eshLicense Lw dose no apply tct an owner of property who
cWilds or Improves thereon;end who contracts !w such p.ojecb with a ALTER-DRAINk VENT-WATER ff/s)
gp[fl am a empt under
Sax,
the Contractoh License Law. BACKFLOW PROTECT.DEVICE FEE SUMMARY
cLJ I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPTY
WORIONAN COMPENSATION DECLARATION FD(T'URES.PER TRAP SCHOOL TAX Y N_
❑1 hereby affirm that I have a rerlifiate of consent to pythesurc,or a� RECEIPT
certlllcate of Workem'Compensatlgnlaurence on rerti(led copy threof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS _
3800,Lab CJ ` PARK FEE Y N
I'oliryY DING OfV
Com CAS EA.SYSTEM-0OVER BUILDING DI VISION FEES
Certified py is hercbyth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy is filed with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA 200FT Date Recei t#
(Thisaectlon need eat ed completed tithe permitb!canone hundred dollars
(81 O)grfess) WATER HEATER W/VENT/EFCTR ENERGYFEE Y N
I certify thatInthe person many he workmanner
forwhlbthis pemdtb Issued,
7 shall not employ any,dawn in any manner n a to become subject to the WATER SYSTEM/TREATING
Workea'Compeaution Lawns o(Gllfgmis.Date PAID
O Z Applicant NEW RESIDENTIAL laLMB,
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you SQ,FT, Date Recei t#
should become subject to the Workers'Compensat Ion peavisloa of the Labor TOTAL:
N Code,you mu at forthwith mmplywlthauch provbioamthis permit ahallbe B
deemed revoked. FEE
W GCONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
a Ihereby affirm that there is a construction lending agency for the perfoperform, TOTAL: 0 ELECTRIC FEE
ante of the work for which this permit In Issued(Sec.3097,CIv.C)
(,) O Lender.N. G)
PLUMBING FEE s�
(y l— LAAdAr'AAdd. 4n. MECHANICAL PERMIT PGE MECHANICAL FEE
O W Iment.I hrtl to ave
ply with
all
nd aluntyordinanceshe a dmateation am
M isrornxt.building complywtth ail cttyabyauthylse mpeceeand mate lam PERMIT ISSUANCE FEES PAID:
�. W cityrelaing to enterupoingroatruct{oryanddproprtyhori representative oftM1ls
(• Z cityWenteree to ave,he indemnify an
propertyfor
eas the It purposes. ALTER OR ADD TO MECH.
- (We)agree m save,Inamm�ltts and keep harmien the City of CU ywaya rtlm Date_ ReCelpt#
agalatlbbWlie,judgments,costs and expenses which may In any wayactme AIR IIANDWNG UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of gr ins of thio plan
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Igna of Ap cat%Contatlor to D(HAUSFHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuwm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
materlafadefined by the Cupertino Municipal Code,Chapter 9AZ and the - Date Recei W
biealthand Safety Cede Sectlon25532(a)7 HEATING UNIT(OVER 100,000 BTU) -TOTAL: Ixs-T�
❑ Yes fn No
Will the applicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardom air contaminants as defined by the Bay Area Air RAW Qua llty Management District? BOILER-COMP OHP OR 100,0(ID BTU) �afARfO�'
4 Ye 11 No
have rcadthehaza oue mated.larequirementsundeTChapter6.95of 901MR-COMP(OVER 100,000 BTU) JUN 2 61990
the Callfomia Health h Safety Code,Suctions 25505,25S33 and 75536.I
understand that itthebullding does eat cvrzenlly have,tenant,that It is my NEW RESIDENTIAL MECH. SQFI -
responsibility to notify the occupant of the mqulrcment.which at be met
prior to Issuance of a Certificate of Occupancy. ift Q*
Owner or authorized agent Date ISSUEDBY: a
TOTAL:
OFFICE COPY