20973 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed Identification PEVNIlT NO.
Building Address: 20973 powfee� Ape- e rn0rX T�•e-e
one: A A
WfLt Llnl F2`( –$4,75 CITY OF CUPERTINO-BUILDING DIVISION
enntnanranam: C ueL.No: APPLICATION / PERMIT [ l
BNLDING-ELECTRICA4PLUMBING-M CATEGORY CONTROL 0
Amhtied/Engloser. ` Llc.No: IGHAMCAL
7i/Yt BUILDING PERMIT INFO
QTr ELECTRIC PERMIT FEE
Addmv: PERMIT ISSUANCE - (� ❑ ❑ ❑ ❑
LImthat ED CONTRACTOR'S DECLARATION
I hereby o700fttlam Bcen3 ofthemert under snessa dPro Chains 9(omnd my APPLIANCES-RESIDENTIAL JOB DESCRIITION
ingwlth5i f i1 f000Iof it effect oftha Buslnnsand ProfrsslansCade,and my
III Is In lull effect. PANELS }^� ��
Llcensa Chss Lica S7�7B ((,'1—
Date�— Co ARCHIP�jr —UP TO 200 ANTS
TECTS DECLARAT ON OOA.MI'S
0 Z I understand my plans shall be used v pubpublicrecords. OVER
e
records. OVER 1000 AMPS SQ.f7.FLOOR AR 5/SQ.FT.
PO
q d I=) Licensed Professional SIGNS ELECTRICAL
<Q OWNER-BUILDER DECLARATION SPECIALCBRCUIT/MISC
I hereby afflim that Iamesempt fmmthe Contractor's License law fee the
pt-Q following reason.(Section 70/15,Business and Pmfesslons Cade:Any city or
OZ W cauntywhlchrequlsesapermittomrotmd,alteg4 pmve,deirolbh,ornpalr TEMP METER ORIOLE INST. -00
5 .a my tructurepri.rt.itslsauance,robonqulrestheappllcant/onuchpereelt to
TOWER DEVICES
Cfileo i signed statement that he b licensed pursuant it the providers70M) of the
3ivi-
Q Cont ofthe usinLiceus Law(Chapter9Commencing with Section hereto/ and SWIMMINGIDOLELECTRIC
Ssbbasisfo Budvrsund Prdession. Anyvirthaheb excm thenfomand VALUATION
the basis for the alleged ind thlon. Any violation of mlty 7011.5 re any OUILETSSWRCHLSFIXI-URFS
EW5 appli ntfaraperMtsubjeds theappllcant t oacivli penalty door core than
fiWndrednerofI he
r. NEW RESIDFN'fIAL ELEC]'R SQ.FT. STORIES TYPECONSTRUCTION
?¢ c,Ympo»owner of the property,or my employers with wages as thele sole
pensation,B,uuo ma work,and the structurerth not Intended or ioffend for
Vp .die 6otappl,to an ower of proProfessiperty
Coda:The or impirmes License law
[�V� docs nm,such torn owner dprough who bulmporimprwvided tatand
who dwssuchwork hlmseBorthmagh Hsownemployen,prwidedthatvrch OCC CROUP R[S.ONITS
improwersetsamem Intended orotfered forsale.I(however,thebulldingw TOTAL: _v0
improvement issold withlnoneyearofcwnpldwn,theowner-bullderwill have
tis rdenofpmving that he did nutbuid orimprove for Purpose ofssle.I. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as merner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7034,Bina
usessnd Pofealmo&Code:
The Contndars License Law dons nn apply to an owner of property who ALTER-DRAINk VFM-WATER
Wilds or Imp.thereon, and who contract. for such p1jects with a
�g0tfact.Rs)Ihim punuantt,theCm,t.dor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am ro t under B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RELEPI a
WORKMANCOh USSATIONDECLARATION plC1FIXTURESPER TRAP At
TAX Y_ N_
❑I hereby affirm that I have a¢ ca
rti0te of consent to self-Insure,or• RECEIPT If
ortlficate cAWorkers'Comperuatlors l ruurance or a certified copy thereof fbec. GAS E.A.SYSESEI INCA OUTLETS Y N
3800,Lab C.)
Policy a GAS EA.SYSTEM.OVER 4 DING DT
Com any BUILDING DIVISION FEES
�CenlBm copy b hereby furnished
❑Certfled copy V flied with the city inspection division. GREASE/INDUSIRL WASTE I PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWFRSAMTARY-STORM EA.NIOFI. Date RCtt'1 !#
(This section need nut be complded 1(mc permit V fw ane hundmd dollars
f5100or eKifythat
J WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
I certify thato the person in of mework so as to bicon permit is ho I he
1 shall not employ any person l any manner n v to bemuse subject to the WATER SYSTEM/TREATING
Workeri Campensatlon I�ws o/Gli(ornla.Date
O = Applicant NEW RESIDENTIAL PLMB. ✓Q Date RCtt'1 tN
Z O mNOTICETO APPLICANT;If,after making thisCertiflate of Esemptlon,you
Fshould beees.bjact to the Worker Comparuatlon pmvislov ofthe Labor TOTAL
LU :
(n o
Code, forthwith comply with much pvlsmm orthit permit shall be - BUILDING FEE 1 W > deemed revoked.
— CONSTRUCTION LENDING AGENCY
a o sElsMlc FEE
I hembyof the work for tthen Vacomwdion Teed c. agencyfarthe pedorrtr ELECTRIC FEE
7 Z arm otthewudlorwhich thb permit 1,;issued(Sec.3097,Civ.C.) TOTAL: . 00-� ~-
U O Lender'.Name PLUMBING FEE
14, H lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedlfy that i have read this mppllutionand statethauab
heove lotmenstwe
S carred. PERMIT ISSUANCE FEES PAID:
relating to building comtmdion,and hereby authmbe mprrsenaHvrs of this j
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. Date Ri tk
V r (WE)agree to
to sa ,Indemnify
nd em if and keep harmless the City of Cupertino eCeP
ga g pcnvs which may In any wayacorua AIRHANDONGUMT(TOIO,"O m)
SUBTOTAL:
agalrut Bald Cit In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,0XICFM) CONSTRUCTION TAX
SignatureotAppllcant/Contrador Date IXEiAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrduus HEATING UNIT 60]W,=BTU) Date RCCCi tN
nuterul as duflnad by the Cupertino Munldpal Cad,Chapter 9.17,and the
I(ealth and Safety Code Section M37(a)? I MATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ycsb No
Will the applicant or futum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSjjA�DATE
which emit hii.exi us aon
ir ctaminants m dented by the Bay Ama Air P
Quality Management District? BOILER-COMP(3EB'OR 100,00)BTU)
4 Yes n No
I� havemdthehaaa ous materials mqulremenes under Chapter 695 of BOILER-COMP(OVERIM'"0TIA SECp
41990
the California ilealth k SifrtyCod,Sectiom 75505,75533 and 2SSM, I
understand that if the building docs not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. S'Q.17.
ropovibility to notify the occupant of the requirements which must be met City of.Cupertino
prior to issuance d a Certificate of Occupancy.
Owner or awhwiud agent Date 1-
TOTAL: ISSUED 6Y:�. ✓`✓ s
OFFICE COPY