20937 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PERMIT NO.
Building Address: 20937
206 e
en ossa: one:
C 53-0567 CITY OF CUPERTINO-BUILDING DIVISIONtw ^
.
Cc m,' — M#aA Lk.No 9C APPLICATION /PERMIT p1-zJ—u
r O /al / BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL#
Arch /Englneer. 4j,.No:
a�
QTY ELECIRICPERMIT FEE BUILDING PERMIT INFO
Add—)63Z ll oak- .Dr- S'5— PERMIT ISSUANCE El 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
thereby
affirmthat l am Beased under provlsionsof Chapter9(commene APPLIANCES-FIESIDENTIA, TOB DESCRIPTION
IngwithSedtan7000)of DiAsion3ofthe Buslnemand ProfeWonsCodde,and my
license
1.
affect.
Da Mia bssf-.anConPANELS
#dor D 9 rRA �1 X11-1000 AM ���
ARCHITECTS DECLARATION
a0Z I understand my plan@shall be used as public records. OVER 1000 AMV W SQ.Fr.FLOOR AREA $/SQ.Fr.
Limned Professional SIGN LDCTRI
OWNER-BULDea DECLARATION SPEC
ZE, followingIhemum.(lutlam31.5,B learn the Contractor's License
law far the
O2Lcmntywremor.(Schon701.5,Bmtmdandr,Professions Code:Mydtyor T
EMP. POL IN .
cwnty which requlresa perndtbcon@tntalter, aprovgdemolIs),orrepalr
S anyalrucwrtpriartolbiavunce,alsorcqulrolheapplfant for oath permit to
L5 O file a signed statement that he Is licensed pursuant to the provIslon@ of the
G61 Contndor's Lknue Law(Chapter9(mmmendng with Section 7000)of Divi- ECI7II
N�5 slon3.fth.Butl mend Pro(emWn@Code)ortheh.bexempttherefromand VALUATION
the bats for the alleged exemption. Any violation of Section 70315 by any ^ �G
applicant fora permitsubjedatheappbcanttoadvll proakyofect marethan DDTLETSSWH'CHES- Ge� l
five hundred dollars($SM. NEW RESIDENTIAL ELECTR so Fr STORIES TYPECONSTRUCTTON
�n ❑I,as owner of the property,or my employes with wages as their sale
compen@atlon,will do the work and the structure Isnot Intended or offered for
MI mle(Sec.70K Nauss.and Profession@ Code:The Contractors License Law
$$ does not apply to an owner M property who Wilda or improves thereon,and OCC.GROUP RES UNITS
whodevesuchwork himself orthmgh Nsownemplayees,provided thatsach
Improvements are not Intended oroffercd(mule.If,hmvever,thebuilding or TOTAL:
Improvement) wtdwithlnam)Barofcompletton,theowner-buBderwill have
N
t en of proving that he did not Wild or Improve for purpose of sale.). QD
TY, PLUMBING PERMIT FEE FLOD ZONE APN
LI,as owner of the property,am exclusively cantnding with licensed PERMIT ISSUANCE
mntndom to construct the project(Sec.7044,Business and Professions Code:
The Conrado'.Llmme Law don not apply to sa owner of property who ALTER-DRAW&VENT-WATER(11N!N
Wilds or Improves thereon,and who commm (ce such ptoas jewith a FEE SUMMARY
�gRtTactor(a)licensed Pursuant to the Contractor's Llan.I . BACK FLOW PROTECT.DEVICE
LJ I am exempt under See, B k P C for this meson
DRAINS FLOOR ,RI
OUTSIDE FEES
ROOF,AREA, SANITARY Y N_
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FlXNItFS PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have a certificate of consent to ml(-Inwrc,m e RHCEPT#
camflrateof"Alums'CorperuaHon Insurance me artlfied copythereof(5ec. CAS EA.SYSTEM-17NC.d OUTLETS PARK FEE Y N
3800,Lab CJ RECEIPT
Policy# CAS EA.SYBI£M-OVER 6(EA)
Com n4, � BUILDING DIVISION FEES
CA
copy Is hereby furnished. GREASE/INDUSIRL WASTE INT'IXCEPTOR PLANCHECK FEE
�Cahiied copy Is filed with the city Impaction division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM ITA 200FT Date Recei tit
(Thissetio ncednolbecompldedlfthe Ne tlafmonehundreddollare
($100)mla WATER HFA77R W/VENT/ELECTR ENERGYFE•E Y_ N_
Imnifyt atto a perfomunm of the work for wed this rtnitblmued,
I shall not c to any persan In any manner sa bit to the WATER SYSTEM/TREATING Pplp
Workca Cc moon a of Califorene Date U
Z Applicant NEWRESIDENTIALPLMB. SQFT. Date Recei to
Z O NOUCET I after making thin Cenificateof Exemptice,you
Fshould Wcomesub' Workeri Compen@atim pnevialms ofthe Labor TOTAL:
VT Codgyou=9forthwith comply with each provblon@or this permitshail be tz
LU deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there Is a mntrudion lending agency for the perform- TOTAL:
ELECTRIC FEE
M Z arm oftheworkforwhlciethis permit Is Issued(Sec.3097,C1v.CJ
V O Lenders Nang - PLUMBING FEE
LL I— Lenders Address - QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W IanlfythatlMvemadthbappUmtlonandmtethatlheabmelnfor Hm
G Iscorret,I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
reixting tobuilding comlrudlon,and hereby authorlae mann aentstives of/his
F N cttytae upanthe above-menlloned property for Inspection purpoem.` ALTER OR ADD 7Ll MECH.
Z Date Recei tp
(We a to cove,Indemnity in d keep harmless the City y Cupertino o
V agaln@t lab Hes,I.Id nts,coma and expenen which may any ora amue AIR HANDLING UNIT(fO l0,f100CFM) SUBTOTAL:
agalmt City In n nae of IZO;=1in ofthis
2 6 ATR HANDLING UNIT(Oven 10,000CFM) CONSTRUCTION TAX
5lgmture App nt/C tr tm Dat EXHAUST HOOD IW/DIK77 CONSTRUCTION TAX PAID:
U DO SMATERIALSDISCL.OS RE
Will the apPHan or building occupant or adle haurdous HEATING UNIT(N 100,0110 BTU Date Recei tN
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Code Section 2SS32(a)7 HEATING UNIT(OVER 100,000 BTU TOTAL:
qYea (��-rI No
Ol the zpplicant or lawn,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I DATE
which emit harandous air costarnimeds as deflated by the Bay Arca Air
lombility
ement DlsMd7 BOILER-CAMP OHP OR If10,000 BT'U
❑No /,,.�; ?J 1990
thehazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
ealth h Safety Code,Sections 25505,25533 and 25536.1
tlfthe WHdingdceanotcvmntiyhaveatenanLthtltIsmy NEW RESIDENTIAL MECH. SQFT /Eaasso notify the occupant of the requirements whicM1 must be metcaYt e4T1!ceof ate ofOccvpa ncy. �'
2�
ser aalh
aft
he TOTAL: I�UED BY:�
OFFICE COPY