20383 (2) APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
BvBding Address: 20383
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t-nweer. ansa: / 4'1`a/
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' li[/L /�/ -J�iCITY OF CUPERTINBUILDING DIVISION
' CoatractoisName: Lie.No:
APP/L•ICATION / PERMIT
x BUILDINS-ELECTRIC I nyM TNGMECSIAMCAL CATEGORYCONTROLr ^y
Architect/Engineer. Llc.No: - IDC• J
1.
.it. f .' 'I "- I P ran 1'FEEf -'''',,i;,BUILDI�IINN�GPERMMMIITa,�INFO
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Address: P' ^ E J�—�, G"
LICENSEDCONTRACEOR'SDECLARATION � 'k�W ,t
Ihereby affirm that l am licensed under provisions of Chapter 9(commere, AMLIAWRIlSIL ]OB DESCREP770N
Ing with Section 7000)of Division 3 ofthe Business and Pro(emionsCode,and my _
license is in NU force and effect. P G�,.f�A /• � �;�.�
Limn P�TCca
rc Cbss LION /
Date Contractor �
ARCHITECTS DECLARATION 4 '
NO ZpO I understand my plans shall be,used as public rcmrds. I - _ SQ.IT.FLOOR AREA ' $/SQ.I7.
`-tke b`j Licensed Professional NS EL CAL - - -- '31.1• Cr a`--
t
6LkT' OWNER-BUILDER DECLARATION SPECIAL CIRC T/Ma..L� !,
7sa• '„Za � Ihercbya(tirtn that lam exempt from the Contractor's l.Irense Law for the Lt(bc. P—ekwy6- Y
O
following reason.(Section 7031.5,Business and Professions Code:Any city or Z H TEMP.ME O S .
pm anystywhichcturn requires rto it perMttomwtrouiresthect,alter, aprovgdemsuch,orrepair
'� anya signed statement
that he
rcqulretheapplicantfor such pemdn° POWERD ,
file a stoned statement that he Is licensed pursuant to the provisions of the
p�Ow Contractor's License Law(Chapter9(commencingwithSection70M)ofDivl-
O SWIMMING L ECTEC
ee on3 of the Businessand l'rofessbra Code)or Mat he Vexempt therefromand VALUA710b(..-
'^I the basis for the alleged exemption: Any violation of Section 7031.5 by any .-L - O /s1 T+) U� -
<.e appllanlfora perrrdt subjects the applicant to a civil penalty of not rrorethan 7� O[/iLE7SSWITCIiF FIXTURCS �t,3G YlJ\_II
five hundred dollars(e pm NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employee with wages as their sole SQJ-7' STORIES TYPE CONSTRUCTION
rompeneation,willdo the work and the structure Is not Intended or offered for
O ak=.17'09g Basins.and Professions Code:The Contractors License Law
doesnotapplytoan owner ofproperty who Wilds or lmprovesthercon,and
C. who does such work himselforthrough his own employees,provided that suchr�a OCC.GROUT' RIS.UNIT'S
improvements are not Intended or offered for flak.If,however,the building or TOTAL:'kSA J
improvement usoid within oneyearo(compietloo,the owneo-budderwlll have -
- Ih urelen of proving that he did not Wild orimprove for purpose ofsale). QTY, 1 '_ +PLUMBING'PERMIT,�+1"';� '_ FEE, FLOOD ZONE APN
U L as owner of the property,am exclusively mntraning with licensed I pp yp ISSUANCE �1
contractors to construct the project(Sec.7096,Business and Profealom Code:
The Contractor's License Law does eat apply to an owner of property who ALTER-DRAIN VENT-
, Wilds or improves thereon,and who contracts for,such pAvpsss with a WATER(EA) cCD I I '
on actor(s)Bmnwdpunuamtothe Contractor's Llanse Law. - �`;( FEE SUMMARY :
LJ 1 am exempt under Seo B& P C for this reason BACK FLOW PROTECT.DEVICE
OUTSI DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
I 1:17S
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FD(TVRES PER TRAP 0 SCHOOL TAX Y N
❑I he
affirm that 1 have a rertlBa c of consent dl aytheree,ora a RECEIPT X
anlBabof Workeri Compewtlon Insurance ora certified ropythereof(Sec. GAS F.A.SYSTEM-1 INCA Poli lab C.) PARK FTS Y N
Policy
aRECEIPT
CoOCnY GAS-EA.SYS1Ebt-OVER4(FA) BUILDING DIVISION
1510N FEEB
enfied
copy U hercbyte
OCenifled copy V filed withh the city
Irepectlon division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
ity
CERTIFICATE OF FXEMPFION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date
(this section r
ion need not W completed if the permit Is(or one hundred dollars
($]IX)oifyth WATFRHEAITRW/VENT/E.ECTR ENERGY FEE Y N
]snot that employ
any person in any manner
so an to become
eesubjec ito the —
I shall not employ any person in any manner m a to become subject to the
Workca'Compensation Laws of California. AT iR SYSTEM/TRFATING
la.Date PAID
O Z Applicant '
ZO NOTICE be..
OAPPLICt to the
making this pateof Exemption,you NEW RESIDENTIALPLMB. SQFT. Dale ReCe1 I#
should become subject tothe Woiken'Compensation provisions o(the labor TOTAL:. r'T .fir
fA Code,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE L W
deemed revoked.
cep CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyafRrmthat them is a construction lending agency for the perform- ELECTRIC FEE I 3
ti I
Z anee of the work(or which this permit is Issued(Sec.3097,Civ.C.) ' TOTAL: �'
U O Lenders Nam PLUMBING FEE tl_ Ori
Iy 1= Under'.Add rea QTY. MECHANICAC'I ERMIT` FEE' MECHANICAL FEE Qct
.O W Ianlfy that]have read thisapplicatlonand statethat theaboveinformatlen ^
IL cormet.I agrestocomplywith all cityand countyordlnancesandstatelaws PERMIT ISSUANCE 1 4s.= FEES PAID: ,
} W relatingtobuilding construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. ♦� -Date RLPceI t#
(We)agree to save,Indemnify an d keep harMess the City of Cu pert Ino P
against is Ilitlee,judgments,costsand expenses which may In anyway accrue - ASR HANDLING UMT CFO 10,000 CFM) SUBTOTAL:
against aseq
said City in conuenceof the granting of this permit.
�'"!V-• AIR HANDLING UMT(OVER 10,000CFM) CONSTRUCTION TAX
'ignsture of Applicant/Contractor Date D(HAUST HOOD(W/DLTC0 CONSTRUCTION TAX PAID: '
' HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HFATING UNIT(TO 100,000 BTU)
material as defined by the Cu ails.Municipal Code,Cha 9.1 Date Receipt#'
y p p pier 2 and the -
HealthandSafetyCeIS, ion 25532(a)? HEATING UNIT I W,000 BTU) TOTAL:
❑ Yes m s
- - - Will thea ppi(cant atom building occupant use equipment or devices VENTILATION FAN RESID) +(� iI $ NCE DATE
., t whichemlt umdousalrcontaminantsasdefinedbytheDayAreaAir 199D
f''•
Quality Management District?. BOILER-COMP OHP OR 100,000 BTU)
Era - AUG -
'�'�� rcadihehazas�smaferials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California health k Suety Code.Sections 25505,25S33 and 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Ff. City of CluVr.ftl
rnppnsiblllty to notify the occupant of the requirements which at be met
prior to Lata nee of a Certificate of Oceupa nry. w
nerorauthonzed agentDate
TOTAL: ISSUE TOTAL:
`OFFICE COPY