20586 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification JALL CO F�r �O� P�R� PITLMIT NO.
Building Address: 20586 0�(�
!D(Z3 A/. Wv4 RP du E1e /,✓at suln. 995 M 9.5v/d G l8/6
ossa: ane: ,3 A A
nem !�(RN,//} jl,�r�!'j co 2S]-j CITY OF CUPERTINO-BUILDING DIVISION p /�
.no-a .r%,Name: LcN« APPLICATION / PERMIT �� ( C�
�"' /iVC' d w • BUILDING-ELEC3RICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/ gfneer. Lie.No:
A/J", IOc 1-40�FeTrL[6QTY ELECTRICPERM FEE BUILDING PERMIT INFO
�
Address: /4-3 bb A/q ✓F- S /A
, SAPevI/I PERMITISSUANCE BLOC-71:17371 PLUME MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION64. /03
I hereby affirm that lam licensed under provisi.ns.f Chapbr 9(commenc APPLIANCESRESIDE L JOB DPSCRn'IION
Ingwlth Sedt..700D)of Division3ofthe Bulincasand Prof.i..n C ,andmy
license is In fun force and effect. PANELS
Licenxchm Lic.N CL)
Date Contactor
ARCHITECT'S DECLARATION IDI-IOW MI'S
es0 Z I understand my plaru shallbs Band as public recondw iOVER100VAMPS SQ.IT.FLOOR AREA S/SQ.FT.
O
Z�
Licensed Professional 111rNIECA
OWNER-BUILDER DECLARATION /MISCIhembyaffirrnthatlamexempt fromtheContractorsLlcenx law forthefollowing reason.(Section 70315,Businessand ProfessionsCode:Any city orGG W county which requlresa permit tocomtruct,alteq Improve,demolish,orrepair OR POLE INST.
am�G any structure prior to its Issuance.also require,the applicant for such permit to
o.O file a signed statement that he is licensed pursuant to the provisions of the POWERDEVICES
°3 G
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
slon3ofthe Businessand ProfessloneCode)orthat hefaexempttherefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIX'TURES
SMGS applicant fora permit sub)ocsthe applicant to a civil penalty nines morethart OMO
five hundred dollars(SAO). NEW RESIDENTIALELECTRFT.
?< ❑I,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure Is not Intended or offered for
5 ❑ sale(Sec.7066,Business and Professions Code:The Contractors License law
does nes apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
who doessuch work himself orthma gh his own employees,provided that such
improvements am nes intended or offered for sale.If,however,the building or TOTAL:
Improvement fasold withinoneyrar.(c.mpl&iogtM owner-bunderwillhave
ttjllj�urden of proving that he did not bond or improve for purpose ofsale.). QTY. PLUMBING PER T FEE
,K as owner of the m FLOOD DONE APN
property,am exclusively contracting with licensed PERMIT ISSUANCE
meContr t.mr License
the project(Sec.apply
Business a nand of property
Code:
The Contractors License 1caw dcea nes apply tct an owner paleface,property who ALTER-DRAIN&
builds t r Improves tber1 n,and who contracts !or such with a
VAUMT
cgRy(ador(s)Ilttnxd pua�iant to Ne Contranor's Llmnx Law. BACK T FEE SUMMARY
u al`m II B&P C for this reason "
er$.eco a_ DRAIN R R GO
TS
E AREA, ND. SANITARY Y N_
• Owner ` Date TI . RECEIPT
WORK. RATION DECLARATION
❑I hereby a((Irm That I have a artl0cate of consent to sen-Insure,oraFECSCHOOL TAX Y N
RECEIPT N
cenificateofWorkers'Comperuatim Insurancema certlfL.d copythereof(Sec. GA FA.SYkTlM-I INC.40UTLETS PARK FEE Y N
3800,Lab CJ
Com n Policy# G EA.SYSTEM-OVER 4(EA) Ica (,� RECEfPI'N
�a y 1''l I BUILDING DIVISION FEES
I Icenined copy ls hereby furnished. PLANCHECK FEE
sniffed copy 6 filed with the city inspection division. GREASE/INDUSCRLW I FP
r-- CERTIFICATE OF EXEMPTION FROM WORKERS' GREE PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. -�' DRIC RCmI 1#
(Thlsxcllou need not be completed If the permit is forms,hundred dollars
(S1W)orlem.) WATER HEATER W/VENT'/ELECTR ENERGY FEE Y_ N_
I cenify that In the performance of the work for which this permit Is fasted,
I shall not employ any person In any manner so n to become subject to the WATER SYSTEM/TREATING
Workers'Compensauonlaws of California.Date PAID
ZZ Applicant NEWRESIDENTIALPLMB. SQFT. Date Remi t#
O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
i- should become sub)ect to the Worlam'Compewtlon provisionsof the Labor TOTAL:
W Code,you mast forthwith comply with such provisions or this permit shall W BUILDING FEE X 6140
LU > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
b W
D Z ante of the work(or which this permit issued(Ser.3097,Cle.C.) TOTAL:
me PLUMBING FEE
0O Tender.Na
LL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
lartifythatl have read thlsappncation and rtatcthatibeaboveinformatim
O W
1 Iscomed.I dgrmtocomplywlth allcityand ceuntyordinancesand statelaws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hemicyauthorteemprexntaivesofthtai
N n ALTER OR ADD TO MECH.
F city toemeruponlhea v me Boned property for WpttH.n purposes.
_ Z Date Receipt#
(We)agree to save ldemnify and keep harMessthe City.(Cupertino U against liabilities,judg lib,costs and expense whlcbmaylnanywayseems AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ante of the granting of this pstrul CONSTRUCTION TAX
AIR]iANDENCl1Nff(OV�RIO,ODOCFTN)
Signature of Appn res or IC
Date EXHAUST HOOD CONSTRUCTION TAX PAID:
A RDOUS MATERIALSDISCLOSURE
Will the applicant or forms building occupant store or handle hacandous HEATING UNIT UO 101),000 BTU) Date Recej t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
I lealth and Safety Cod a Im 25532(a)t HEATING UNIT(OVER 1W,IXID BTU) TOTAL:
❑ Yrs R&No
Will the applicant.rfuture building occupant use equipments devices VEMDLATION RAN(SINGLE RESIDE ISSUp(�C�ATE
which emit havardous air contaminants as defined by the Bay Area Air �"F�111J
.
Quality Management Dial'ct7 BOILER-COMP 0HP OR 100,0W BTU)
4Yea No
have read the hoz nus materials requ Immenb under Chapter 6.95 of 1101LER-COMP(OVER 1W,000 BTU) Jui% ,1 ;j 199J
the California Health&Safety Code,Sections 75505,25513 and 25536.I
understandtlutifthe ildingdossnoteurrentlyhavca tenant,that it ls my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to nest , hemcupantofthsrvquhv nt,whichmustW.t
i0cateof Occupancy. 6 i 9 Cibf of Cupertino
Owner or authoriv Date ISSUEDBY:NJ, )nT U
TOTAL:
OFFICE COPY