20633 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proem Identification PERMIT NO,
Building Address: 20633
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adk A G1PO2rA./nVv 0s-V/ y
scan. one: A
/C/{AIZZ k9AY7401V CITY OF CUPERTINO-BUILDING DIVISION /'
comm,,',Namrc: 6 LIe.No: APPLICATION / PERMIT ^—
14
1 BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
A.hftem/Engimer.- Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmsx PERMIT ISSUANCE ❑ 1:1 11LICENSED CONTRACTOR'S DECLARATION
I hely' at.irmthatlamlkm3oftheerindasaonsof Cssions9de,and c A1'PDANCFSRE9DENTlAL ]OB DESCRIPTION
Ingweh5tttian force of Division Jo(the Buslneuandl'rofesslona Code,and m
LI.. Is Ins force and effect. PANELS a�
Date Class Lk.Y
Date Contractor UP TO 200AMPS
ARCHITECTS DECLARATION 101-1000 AMPS
{Qq ceO 70 I understand my plata shall be used u public record.. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
E (1 Licensed Professional SIGNS ELFJCTJIC&V
OWNER-BUILDER DECLARATION SI mkcwl�vwv ,
7to' I herebyaflmothat l amexempt lrem the Contractor's License Law fnrthe
following reason.(Section 7071.5,Business and Professions Code:Any city or N
F4 muntywhkhmqui aperoutWmutmc;ilter,Impn de. h,orrepilr
Q any atromure statement
that
h,alaorequkndsout the lorsuions of dtto p0 �q
Q U file a signed mtement that he at licensed punuaN to the proWslou of the
way Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- VALUATION
sion3ofthe Businnsand PMesslouCode)or<hat he laexemp therefmmand SWIMMING E
G Nc baela for the alleged exemption. Any violation, Section 7m L5 by any OUTLE TCHESFI
applicant fora permit ubjecta the applicant to a civil penalty of not mom than V O
v ndred dolI:Z%5ON.
owner of the property,or my employees with wages as their sole W DG):NU7AL ELACTR FL. STORIES TYPE CONSTRUCTION
C 6 mpenubon,wBldothe work and thestructure la not Intended or offered for
'$ ❑ sale(Sec.7044,Business and Professlmu Code:The Contractor.Llceue Law
E�j r3$ does not apply to an owner of property who builds or improvn themo and OCC.GROUP RES UNITS
whodoessuchworkhlmselfmthroughhlsownemployees,pmvidedthaits
improvement are not intend d oroffemed fwaale.If,however,thebullding or TOTAL:
improvementissokl withinomyearofcompletb theowner-bullderw111 have
tlW.Ifurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBINGPER IT FEE
FLOOD ZINE APN
LJ
L as owner of the Property,am exclusively si Business
andcontractingPro with licensed ppgMTp ISSUANCE
contractors construct the project(Sect apply
evilness and of property
Code:
The Contractor's Imam e.tha Law den who
apply tct u owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.t r Improve.[hereon, and who mune.for anrh plopm with a FEE SUMMARY
cLBjIarexemtundd po er ant Sec.
the ContractorsLicense Law. BACK FLOW PROTECT.DEVICE
(_f I am exempt under Sec. B&P C for that moon
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N
. Owner Date RECER'I N
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOL TAX Y N
Of hereby a((Irm that I have a certificate of consent to self-inmre,or a RECEIPT
certifleateofWorkemi Compewtlon l�uunnaara certltkd copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3Blc Lab C.) RECEIPT N
Poliry N CAS EA.SYSTEM-OVER 4(PA)
Co����m +.a+ny BUILDING DIVISION FEES
I (Certified copy at herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
L�Ji Certified mpy at filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 300FT Date Recei t# 'C15(This section need not be completd If the permit is for one hundred dollar
(SLOB or lend WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of thework torwhlch this permit fa bound,
I shag not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workem'Compen..lion laws of California.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Rece1 t#
Z O NOTICE TO APPLICANT-.It,
,after making that Certificate of Exemption,you
should become subject to the Workem'Compeuatfon provision of the Labor TOTAL:
N Code,you=at fort hwith comply with such provisions or this permit mail be BUILDING
FEE 001
W j "tented revoked.
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby atfirmthat there at a mutromion landing agency for the perform ELECTRIC FEE
D O ance ofthe work ferwhichthat permit atlawed(Sec.W97,CIv.C.) TOTAL:
I<adto.Name PLUMBING FEE
LL 1= Lander'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icortilythm l haveread this application."state that theabovelnformatlon
at correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N miatingto building construction,and hereby authorise representatives ofthis
city In enter upon the above-mentioned property for Inspection purposes, ALTER OR ADDTO MECH.
? (We)agree to cave,indemnify an If keep harmless the City of Cupertino - Date Receipt#
V
against liabilities,Pdgmenre,costs and expenses which may In anywayaccom AIR HANDLING UNIT ITO I0,000 CFM) SUBTOTAL:
agai said City N constxryence of the gra g of thla permit.
MR HANDLING UNIT(OVER I0,000CFMI CONSTRUCTION TAX
lgnatumaf Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATINGUNIT(TO100,0DOBTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Code Section 25531(a)7 - HEATING UNIT(OVER 100,000 BTUs TOTAL:
❑Ynml��—,I No
Will the applicant or futae building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which rout hazardous air contaminants as defined by the Bay Area Air b A R^
Illy Management DlsWm7 BOILER-COMP C31D OR 100,000 BTU) {�•(��M7
L-I Y. ❑No (}
I haat
vcmadthchm ous materials requirements under Chapter 6.95 of BOILER-CONIP(OVER 100,000 BTI!) JUL J 7J3U
the Califontla Health&Safety Code,Sectbu 25505,25533 and 25534.I
u ode=odthat if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.FT
resporelbWty to net lfy the occupant of the requirements which at be rrvt
prior to Issuance of a Certificate of Ocmps nry.
Owner or authorized agent Date
TUTAL: ISSUED BY �'YIW{J:'++a�Ox�U
OFFICE COPY