20683 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification I - PFRMITNO.
Building Address: - V 20683 O^IMAn3
wners Name: one: G AL DA I jL
444 Q L CITYOFCUPERTINO-BUILDING DIVISION
C° a "•^° Lk." APPLICATION I PERMIT ( Cl
ArchitM/En r. O~ BUILDING-ELECTRICAGPLUMBINC-MECHANICAL CATEGORY CO T n
Llc No: G/
6-IQTY ELECTRIC PERMIT FEE BUI DING PERMIT INFO
Address: 057 C m�2 L PERMIT78SUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION (�
I Mrcby affirm that lam licensed under provisions of Chapter (comaenc- APPLIANCES-RESIDENTIAL JOB DPSCRQ'TION
Ingwlth Sect1.n70(D)of Divlslon3ofthe Buslrassand Profes4onsCode,and my
license la in full form and effect. PANELS
License Clam _ LIC#-!3r4 3
Date - Contract. 4ey�ALS UPT02DOAMPS
ARCHITECTS DECLARATION
Ore 2 1 understand my plaru shaB be used as public remrda OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
RUBLien ed Professional SIGN LECTRICA Sj 9 g 26. OQ
6^by OWNER-BUILDER DECLARATION SPECIALCIRC ISC
s, 7� Thereby affirm that am exempt fromthe Contractor's License Law for the /^ O v2,�
Vi .. following reason.(Section 70315,Business and Professions Code:Any city or METER INS). l O
'acounty which requires permit to commuct,alter,Improve,demolish,or repair
qqq anytruRure Prior to it•Iswance,also requires the applicant for such permit to
Ole.signed statement that he Is)lensed pursuant to the provisions of the
DµI- Contractor's License Law(Chapter9(commencing with SeoIon7000)of DJvi- IW C
theON
basis for t sinwend Pmfemion. Any).dation is exempt therefrom and OOT IO
<.•37
the basis for the alleged exemption. Any violation.(Section.oH5 by any F5
{ay five hundredapermi($5D(fcts the applicant toes civil penalty ofna more than a
five hundred dollars(SSOFI. NEW p A ELECTR SQFr STORIES TYPECONSTRUCTION
GGjlljjj F�I,es owner°f the property,or my employees with wages a•1Mir a
compensation,will dothework,andthestmcture in not Intended or offered or ' /
0 sale(See 7044,B..inem and Prvfembra Code:TM Contractors Lierue is I/ x
SQ does Wt apply to an owner of property who builds or Improves theme an OCC.GROUP RFSUNITS
who doeseuch work himseUor through his own employees,provkied thatsuch
improvements are not intended or offered for sale.If,however,the building m OTAL:
improvemenituot Rhinoneyearofcomplctieyths.rmr-Wdderw111Aave 4/J
t rdenofprovingthatM did mot buildorlmprove fmpurpme.fnk.). PLUMBINGP FEE FLOODZGNE APN
LJ L as owner of the property,am exclusively entracting with licensed FRL(ITISSUANCE
mntrac tomwtmdtMpmject(Sec7oµBusinemand Profemions Code
TM Cmum cores License Law does nes apply to an owner of property who TER DRArN k V A MAI
wild. or Improves thereon,and who commas for such pWjects with a
�gpj(aeor(s)licensed pursuant to the Contractor's Lumas caw. FEE SUMMARY
LJ I am exemp under Sac. S k P C for this rcaaon BACK FLOW PRVk� EVI
DRAINS FLOOR F,A CO SANITARY Y N_
J. Owner pate RECEBrI'R
,,WORKMAN COMPENSATION DECLARATION FIXTURES SCIdOOLTAX 'Y N
ereby af(Irm that 1 have a certificate of consent to mlLlnsurc,ora RECExT Y
mitlflats.(Workers'Comperwtion fiuimme res certified copythereof(sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FTP Y N
3800,Isis C C Z
RECEIPT M
PoBryM GAS FA.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
Com an r
ECertlB copy is K FEE
berebytthehed.
�CertBled copy is filed withh the city Inspection division. GREASE/INDUSTRL WASTE ININTERCEPTORPLANCHECAA
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID y��0 057 'W'Ob
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OF1' Date Recei [#
(rhi•sedon n
ieed nes be completed If the permit is forom hundred dollars
(sIBO)orlem.) ENERGY FEE Y N
Iertl(ythat in the performance of the work f°rwhlch this permit is issued, WATER HEATER W/VENT/M TR
I shall not employ any person In any manner so as to become subject to ted WATER SYSTEM/TREATING PAID �/(
Workere'Compenutlonrsw•of C•Ilfoml•.Date
OZ Applicant NEW RESIDENTIALPLMB. QFT. Date Recei t#
Z O NOnCETOAPPLICANTAf,ofter makingthb Certificate.(Exempnon,you
should bee ns subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this pemdt shall be
IE IE C dressed revoked. BUILDING -
L CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhercbyatOrmthattMre baconswctlon lendingagenry forth perform TornL: ELECTRIC FEE
n Z anceof the work for which this permit Is 4eued(Sce.3097,Civ.G3
U O Lsndds Name h6A/r5 PLUMBING FEE
LL U Lendto ytnaalave madth app tmnand atatethattheahove lnfomanon QTY.
MECHANICAL PERMIT FEE MECHANICAL FEE
O W incorrect.Iagree to complywith•ll city and c.unty ordinances and stale laws PERMIT ISSUANCE FEE9�I9U
} n' reWing to building constiuctlon,and hereby authorlu representatives m this
H N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,tMemelfy an it keep harmless the City of Cu pertlno Date Recei t# CUP L to
V
against llaba ies,judgments,"a and expenses which may In anyway accrue AIR HANDLING UNTr(TO 10,0DO CFM) SUBTOTAL:
zSol I Id City In ron se99WWnes of ted gramlag od thl.permit.
s(/ 7—� y� AIR HANDLING UNIT(OVER 10,1700CFM) CONSTRUCTION TAX
$gEature of Applicut/Contractor —J4� Dat EXHAUST IIOOD(W/DLK:T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBant or future building occupant store or handle hanrdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
natertaI as defined by the Cuperti.o Municipal Code,Chapter 9.1 2,and the
Flealth and Safety CodSgMI°n 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
0 Yes Q�QINo
Will the applkant AIN.
occupant use equipment or devices VE FAN(SINGLE RFSID7 IS$ TE
which emit havrdow air contaminants as defined by the Bay Area AB
BOILER-COMP DHP OR I(IQOM BTU) ser-
a p Q(�(�
Quality Mansgemcnt a ct7 - t7l;y (�.I OI "9%
4Yca e.
have read tMh o matedab requirements under Chapter 6.95 of BOILCR-COMP(OVI7i 100,000 BTU)
the California I lealth k Safety Code,Sections 25505,25533 and 25534.1 - - ss.`
understand that if the building does nes currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
res Ibllityon.lify the occupant he rryulre ntswhkhmust MTM
Pr 1 I.. mf CertlTicam of pancy. JA/�b
nerm..thonredaent / / ate ISSUEDB IMAX
J
TOTAL:
OFFICE COPY