20564 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PERMIT NO.
Building Acyness: 20564
0 3 7/ y+er
ner. ams: -9—C /Lf CITY OF CUPERTIN06BUILDINGDIVISION G�13-90
Comrade/.Name: LIc.No: APPLICATION /PERMIT l9
R F'p7�p EL/� G S V�C(Qf/yJ�f I/Y( BUILDING-ELECTRICA MUMBINC MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lle.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Acitl22 Sa /LQ,TpG/. Gtyj • S• OS PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapter 9(mmmrn APPLIAN RESIDENITAL JOB DESCRIPTION
legwlth Sedion 70W)o(Division3ofthe Butlumand ProfessionsCocie,and my
licenselatofull force and effect. 4a 9�fl� PANELS
LkaeenClass Lk. G rf— 11
Dale Contractor
ARCHITECTSD RATION TnI
2J
��qquu rsO Zp I understand my plana shall be used as records.res. OVER] SQ.FT.FLOOR AREA S/SQ.FT.
6i E Licensed Pon essioeal R• SIGNS E CAL
OWNEBUILDER DECLARATION PECIAL CULT/ LSC
I hereby a(firmthat l am exempt form the Contractor's License Law for the IT
0 following reason.(Section 70115,Business and Professions Code:Any city or
PH cwntywhlchmqu4 aper tWm.t ct,a)ler,impmve,demolbh,orrepatr ' P. OFIIVLEI
< anystmc mprlortolbbavance,alwrequtreatheapphantfwsuch pe nob'o �q
U file a signed statement that he t limned pursuant to the pmWbu a( the
Contradar's License Law(Chapter 9(commendngwith Section 7000)ofDivi-
1.,30 cion 3 of the Business and Profeselou Code)or that he is exempt therein NGI[)OL EL VALUATION
g the basis for the alleged exemption. Any violation of Sedlon 7031.5 by anyI O` QU
p, <5
applicant fore permit subjectelkeapplicanttoa civil penalty ofnat mnuthen OUTLE WITC CJ
five hundred dollars($SM.
NEW AFS[ AL TR
7�n ❑eactowneroftheproperty,oche employeeswithwages as inhered fo �'ET' SRJWES TYPE CONSTRUCTION
cole(Sm 0KBusAotheworkandions Cduretcwtbranded oroffend(or
O dile(Sec 7061,to avow and fhotmbru Code:The Contractor'sproveLicense Law
does whoclot apply torn umserof propertyrthmugh who
nempor lmprovuted that such
OCG GROUP RES UNITS
e. whodoesentssuch amwork hMsendedoraugh Nsowne.If,ho employees,provided thebuildisuch _
Improvementarenot intendedearofc plsale.If,h er-prhebulldingw TOTAL:
Improvement iseoldwithln oneyeanofcompletbrythcowner-buBderwlll have
th,9,purden of proving that he did not build or improve for purpose ofule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
con reciors utr
to mud the project(Sec 7016,Business and Professions Cede: C
The Contractors License Law don net apply to an owner of property who
builds or Improves thereon,and who contracts far such ptojem with a ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
cq[Lt[ador(a)licensed pursuant b the Contractor's License Law. BACK FLOW PROTECT.DEVICE
1_J I am exempt under Sea B k P C for this reason
CHITSIDEFEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
Of hereby affirm that 1 have a certificate of consent to self-Inwre,or a l RECEIPT N
certificate of Workere'Compematlon Insurancewa certified copy themof(Sea
3800,Lab C.) GAS FA.SYSTEM-1 INC.40UTLETS PARK FFP Y N
Polkyp CAS EA.SYSTEM-OVER RECEIPT#
Com ny BUILDING DIVISION FEES
OCenlfled upytherebytumbhed. CREASE/INDUSIRL WASTE INTERCEPTOR. PLANCHECK FEE
�Cenllled ropy t filed with the dry lupedlon dlWYon.
CERTIFICATE OF F3(EM PITON FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1' Date Reeel t#
RM1lsaectlon need notot Wcompleted
be comppermited If the permit is for one hundred dollars
(Et ')
wrmnrte.. WATER HFATEN W/VENT/ELEGTR ENERGYFEE Y_ N
1 ifythat b the pedmN
oence o(thework(arwch this permit is loved,
I shall not employ any person In any manner ro u to become wbject m ted WATQt SYSTEM/TREATING
Workers Compensation Laws of California.Date
PAID
O Z Applicant Date Retei t#
Z O NOTICE TO APPLICANT:If,after making this Cenlfiate of Exemption,you NEW RESIDENTIAL PLMB. SO.IT.
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
a. N Cade,you at forthwith comply wlthsuch provisions or this permit shall be -
> deemed revoked. — .BUILDING 1 C�
SC CONSTRUCTION LENDING AGENCY SEISMIC FEE SO
Iherebyafl hat there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z arm of the workfor which this permit is tuued(Sm 3097,Civ.C.) c�Ja�
O O Le ddsName PLUMBING FEE p0
U. f Lemice.Addrow QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify thatl haveread thin application and Yalelhattheabove Information
1 mccomet.lagm"o comply with all city and county ordinances and Yate taws PERMIT ISSUANCE FEES PAID:
W ceiling lobuitding construction,and hereby mthonae represntativeaof this
F Z 4Wo
wbuilding
-mentmend property fou bxpedlon purposes. ALTERORADDTOMECH. Date Recei t#
V Z nu fy an d keep harmleu the City of Cupenbo
It ,ewtsand expenses which may In any wayacdue AIR HANDLING UNIT ITC,10,000 CFM) SUBTOTAL:
enceofthegrantingathlspemnit AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
trad r Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
OUS MATERIALS DISCLOSURE
rebullding vavpant afore or handle harardous HEATING UNIT(TO 100,000 RM Date - ROcci t#
materhl act defined by the Cupertino Municipal Code,Chapter 9.12 and the -
HeaithandSafetyCode Sectlun 2SiiMa)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 175.50
(—I Yee ar
I const haaardl the. usair ourc bulldbgompine bythe Bay Area
devices VFNDLA110N PAN(SINGLE READ) ISSUANCE DATE
eMl havardoue air mnlamiuunt ac defined by/he Bay Area Alr RAW
which silty Mawgement rNo BOILER-COMP DIB'DR 100,0(q BTll) '
Yn No (I
ave read Health
a Safety
Code, erequlrememtsun33 and 255346.95 of BOILER-COMP 100,000 BTU) JUN Z 3 NO
the California Health&Sat Code,Sedlou 2550.5,25537 and 7553X, 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECIi. SQ.FT.
rapoulbllityton the ocmpant of the requirement which mu at be mel
prior to tssuanreva rtIfIcm.fOttvpanry. r�
3_ i cf GuperW m
-Ir--
Owner or authO&d agent Date ISSUED BY-.
TOTAL:
OFFICE COPY