20769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERN[1T NO.
Building Address: 20769 O (�n
mess !o ( '�3 nop_T� tO(' Cv Q -f' I h G l6 s9
nen ante: one: A
�Aknp rn��cl�yJENt CITY OF CUPERTINO,BUILDING DIVISION ccgg�
Conte ctorl Name: l use.No: APPLICATION / PERMIT — I T` (Z�
a IS C- 1z 5�� �� BUILDING-ELECTRICALPLUMBINGMECHAMCAL CA Y CONTROL
Architect/Engineer. Lic.Na a�G
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 25` '(5 (3ro4a;4257-04tu' wRL'1 (1.00 ❑ 1:1 1:1PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION DK
I hereby affirm that l am licensed under provisions of Chapter9(comment APPOANCESRESIDENTIAL JOB DESCKIPITON
ingwitteSection 7000)of DiWsion3ofthe Susinemand ProfesslonsCede,and my
license is in full force and effect. n PANELS
License Class r_ m Cl dr-- oL Of(j�
nate_�4�=G cHYEEtor 2011000AMPS
UP TO 2DOAMPS
ARCHITECTSDECLAR ION OVFRIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ore�y O I understand my plant ehaB M used u public records
U E Licensed Professional 1Z SIGNSELECTRICAL kav
Q m OWNER-BUILDER DECLARATION
(-np SPECIAL CEtCIRT/MLSC
Thereby affimnthatlam exempt(romthe Centradori Llcenx Law for the
099F following reason.(Section 70315,Business and Pro(evlons Code:Any city or
cwt hlchre 1 s rmitwmmtmd,alter,lm p TFMP.Mh7Qt OR['OLE INST.
F� ryes gore ape prountiorohahpe air
11 le atmdure tatemeite that
he at ako sed pursuant
t the provisions
ofNt a POWER DEVICES
[4 � file a signed statement that M b licensed pursuant io the provisloro o! the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O sten 3 ofthe Business and Prefemlov Code)or that he is exempttherefromand
0 S the basis for the alleged exemption. Any violation of Sectio70315 by anyOUTLETSSWITCHESH%TURES
not s
p applicant fora permit subjects the applicant to a civil penalty of nmore than
r.�Fy five hundred dellsex(SSoo). NEWRES[DENTULELECTR STORIES TYPE CONSTRUCTION
�j 7 ❑Las owner of the property,or my employees with wages a their sok
compensation,wBldothe work,and thestrudure b not intended or offered for S ��
ja�O sale(Sec.7042 Business and Professions Code:The Contractors License Lana
WS$ does not apply to an owner of property who Wilds or improves thereon,and � _ �Oa� .GROIII' RES.UNITS
who does such work himself or through hisown employees,provided that such
improvements are not intended or offered for sale.If,howevep the building or TOTAL:Io ,7L)
Improvement bsold within one yearofcomplellon,the owner-bulWer will have
ttlakurden of preving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT "E FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contenders to cresimct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does nd apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)Wilds or Improves thereon,and who contracts fee such pSojecu with a FEE SUMMARY
,pfFactm(s)Beamed pursuant to the Contradora License Law. BACK FLOW PROTECT.DEVICE IJ I am exempt under Sec. B&P C for this reason
DRAINS OR FLOROOF,AREA,CONE). SANITARY Y_ N_
• Owner Data RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES—PERTRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,oraRECLII'I'M
certificate mWorkera'Compemallon Insurance ora certifled copy thertrof(See. GAS EA.SYSTEM-1 EVC.4 OUTLETS PARKFEE Y N
3800,lab Cd
RECEIPT If
Policya
cent GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
any
F1 CertOied copy V filed with 1M Certlfled copy b hercbyturncicity ty Inspection division. STGREASE/INDURL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF E%EM PTION FROM WOR K ER S' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WFT Date Recei t#
(fhissedion need not M complded tithe permit b forone hundred dollars
($IW)erless.) WATER FIFATFR W/VENT/ELFOTR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhich this permit is issued,
I shall not employ emer an mannersoas b a jed to the WATER SYSTEM/TREATING
Workers' camp cot La oft - PAID
O Z Applicant as'^+/^ NEW RESIDENTIAL PLMB. SFT. Date Recei t#
Z O
NOD PLTCAFTT:7� er gthis a ifiateC r� of Exemption,you
should become subFctto the aorkera'Compensation provbbreofthe Labor TOTAL:
W Code,you resat forthwith comply with such provisions orthb permit shall be BUILDING FEE
Wj deemed revoked.
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is&construction lendingagency forthe perfum, TOTAL: ELECTRIC FEE L Q
DZ ..co of the work for which this permit is Issued(Sec.3097,Civ.C.)
C-) PLUMBING FEE
� O lender&Name
LL t- lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
1mdilythat l have read this application and statethattheabove information
O W
bcormcf.l agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
> a relating to Wilding construction,and hereby authorins representatives ofthis
N city to enter upon the abovo-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree m e, emnify an d keep haemins the City of CupeMno Date Receipt#
V agaWtikbllltl ,jadgme s to and expenxewhtch mayln anywayamue AIR HANDLING UNIT IT010,000CFM) SUBTOTAL:
gahst said ytnco e off ngo this permit.
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
P C _ Date allAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthcappllant or future building occupant storeor handle haeardous HEATING UNIT(TO 100,000 BTI) Date Receipt
materkl as dented by the Cupertino Munidpal Code,Chapter 9.1 2,and the - �'7
Heallhand Safety Code Ee01on2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: au
❑ Yes M No
Will the applicant or future building occupant use equlpreent or devices VENTILATION FAN(SINGLE RESID) 1$�ANC6''7�IJJ DATE
which ennit havrdow ab contaminants as defined by the Bay Arca Air //
Quality Management District? BOILER-COMP QHPOR 100,IX0 BTU)
4Yes [❑r No II''II// /
have radthehuardoua materials rcquircnaemta under Chapter 6.95 of BOILCILCOMP(OVER IW,Of10 BTU) Nvl
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understa that tithe building does not mrrmtly have a tenant,that it rt my NEW RESIDENTIAL MECH. SQ.FT. cost
pmspo rio rerilBanc nil a Deco ant o(the requlmnrnte which must be coed _=er1=anF`Ina
prix oksuancco Ce of p cy.
—Data
oath r gent Data ISSUED BY..
TOTAL:
OFFICE COPY