20739 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bu.ding Address: f V V 20739 0 7 3 9
8?S �2/� CJ
Uoo D L 1/ lj/ �yJ
ner nen: one: n
CITY OF CUPERTINO-BUILDING DIVISION rA
cont gayme: L N. APPLICATION / PERMIT *�
q 1� BUILDINGELECTRICAI PLUMBINC-MECHAMCAL CATFLORY CONTROL Y
rchi4ci/Engineer. Lic.No:
x� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby.!(Lunt Chat[ant Bcrosed under prwkslons o(CFapter9(mmmmc APPLIANCESRESIDENTIAL ]OB—DESCRHMON.
Ingwlth Sectio 7000)ond efelon3otthe Busimssand ProleesloneCode,cod my
tnge t is In full orm and d(ect. PANELS
License Class Lic.e�a4j?Z/
Date Contractor
ARCHITECT'S DECLARATION 281'1000 AMPS
020 I understand my place shall be used as public record. OVER 1888 AMP5
gyp+ C SQ.FT.FLOOR AREA 5/SQ.FT.
z (a Llaved Prafemlovl SIGNS ELECTRICAL
jn6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Z,�4 hereby.(Arneth.)lame.emptfromth.Cant.d.r.Liren.Ul fwthe
0�- following....(SetloR7031.5,Business and Professions Code:Any city or gFMp METER OR PO IN
county which requires a permit tomcetmct,dter,lmprove,demolish,or repair
�E anystruclure priortoits issuance,also requirmtheappllcent forsuch permit to
file a signed statement that he b llmneed pursuant to the provisions of the POWER DEVICES
3µ Contractor's License law(Chapter 9(mmmendng whirSeedon 7000)of Diel- gWIyL,IDE ICES ELE
O Non3o(the Buslnmemd Profeniom CMe)orthathebemmptthemfmmand VALUATION
'µ' S the barb for the alleged exemptlon. Any violation of Section 78115 by any
« applicant for a pemetsubjets the appllcanito a civil pevlly of not Qmthan OUTLETSSWITCHES
O fivehundred dollars(SM.
❑I,as owner of the property,Or my employees with wages as their sole NEW R FNTIAL EL STORIES TYPE CONSTRUCTION
�^ compensation,wllldothe work.and the structure b not intended or offered for
rule(Sec.70K Business and Profe®Ions Code:The Contractor's License law
3$ docs Rot apply to m owner of property who build@ or Improve.thereon,and
who does such work himself or through his own employees,provided that such OCC.GROUP f UNUS
impmvemenb are not Intended oroffemd(weak.I(,hmvever,thebuildingor TOTAL:
Improvement bold within ovyearofcompletion,the ownerbuilderwlll have
tryurden of Forcing that he did not build orimprove for purpose o(ukJ. QTy, PL NG PERMIT FEE FtpOD ZONE Ph'
LJ L as owner of the property,am exclusively contracting with licensed PERMIT I
contractors to construct the project(Sec.7094,Business and Profession Code:
The Contractor's Llrenae Law don not apply to m owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Imro
pve ,therms and who cont.ts for such Projects with a
�gRtlactor(-)hero dpu.uant to the Coottetola License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I„J I am exempt under Sea B k P C for this recon
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
C31WORKMAN COMPENSATION DECLARATION RECFLT N
hereby affirm that I have a certificate of consent to ml(-Insure,or a FIXTURES ITER TRAP SCHOOL TAX Y_ N—
y certificate ofWorkeraCompervation lvursnceora certified copytherenf(Sm. RECEYTa
3800,lab Q GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
Ibliry M RECEIPT a
Co������mppppppany GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
'diI ICed
crafled copy is herebyth to city GREASE/LNDUSML WASTE INTERCEPTOR PLANCHECK FEE
,'�0��rcrtlled copy b(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP PAID
COMPENSATION INSURANCE
(11-.cuoreard Rd beccmplted lftheperuat bfwevhundred doll.. SEWER-SANITARY-STORM EA.200FT. Date RCCeI t#
(5100)orfy that
WATER HEATER W/VENT/EEM ENERGYFEE Y N
)certify enactorsthe Perf.1.any awwk forwhich tobthis permit e. )isissued,Trial]Rot employ any person In any manner at u m become subject to the WATTS SYSTEM/TREATING
Worlicant mpenmtlon laws of California. Date PAID
z Z Applicant
Z O NOTICETOAPPLICANT.1f,0arrrakil this Cedifkate Ot Exempt ion,you NEW RESIDENTIAL PLMB. SQ}T. Date Recei t#
N
sh.ld ba.rrc sub)t t.tha Worke.'Campematbn provblov of the Labor TOTAL:
Code,you must forthwith comply with such provisions or this pemdi shall he
LU j domed revoked. .E
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Ihfthc a(Rrfo'r at whhereb,comtrotlonlending(Site3 ,Civ.C.)ncy petarm- ELECTRIC FEE
.rare of the work for which fhb permit b blued(Sec.3097,Civ.CJ TOTAL:
C1 O Lender'@ Name PLUMBING FEE
u. != Lender.Addess QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfylhatlluvereadthlsapplimlbnendtate that theabove information
1 hi correct.I agree to comply with a 11 city and oounty ed learner and state laws PERMIT ISSUANCE FEES PAID:
} W relating to bullding construction,and hereby authorize repremntatie.ofthl-
F Z city to enter upon the abov rnrmtkned property lou inspection purposes. ALTER OR ADD TO MECH.
V — (WO agree to neve,indemnify an d keep harmless the City of Cupertino Date Receipt#
againt liabilities,Pdgments,m-teand expenma which may In anyway accrue AIR HANDLING UNIT fro 10,000 CEM)against against mid City In consequence of the granting of this permit.
AIR HA NDLING UNIT(OVER 10,080 CFM) CONSTRUCTION TAX
Signam re of Appllcent/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOLS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or ha nd to harardous HEATING UNIT(TO IDg000 BTT. Date
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the RCCCI t#.
Health and Softy Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑ Yes M No TAL:
Will the applicant or future building occupant use equlpment ordevices VENTILATION PAN(SINGLE RESID) ISSUER DATE
.� which emit havardou@air contaminants as defined by the Bay Area Air
slity Management District) ` BOMER-COMP(3HP OR 100,0(0 BTU) -Ili ' 9 R
t i Y4maity"c'
❑No N1 Lt ¢ 1
ommxterlabrequmments underChapler6.95of BOILER-COMP(OVER 100,000 BTU)
e Gli5a(ecode,Section 25505,25533and25539.1u e tulldingd snot corrently haveatenanq that itbmy NEW R[SIDFN7TAL MECFIreap t of the requrements which must be metprior tf0 anry.
Owner w authorlred agent Date ISSUED BY:
TOTAL:
OFFICE COPY