20467 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build[.,Pro'crt Identification PERMIT NO.
Building Address: G11 I N!
J'd3s S 6-Z- PR�+oo � f 20467
Owner a Name: one: A A A
1P, L�14 6T, CITY OF CUPERTINO-BUILDING DIVISION
c°n a".r.Name: Lie.No: APPLICATION I PERMIT 11 !!
C`Jz V O PZ-um & Z-c fcl 297 BUILDING-ELECTRICAL PLUMBING- CATEGORY
ngiCONTROL N
AnOit ct/Encer. Lie.No:
MECHAMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE El 1:1ItJMJ I ❑
LICENSED CONTRACTORS DECLARATION
I herebyaffvmthat l am licensed under pm,Uionsaf Cha)rter9(commenc- APPLIANCESRESIDENfIAL ]08 DESCRIPTION
Ii...I Section 7000)of IXWect, the Buelnessand ProfnsiomCode,and my qt y
license la in full force and effect, u 2 PANELS �l
License Class( Lic. �7— / a� a ilp�yy�
Date Contactor N(/� --� "V(r—
ARCHLTECTSDE LARATION 2(11'1000 AMPS
NOZZ Iunderstand my pia®shall be used as public records. OVERIODOAMPS SQ.IR.FLOOR AREA S/SQ.hT.
Z(� Licensed Professional AGNS ELECTRICAL
6 ° OWNER-BUILDER DECLARATION
f' thereby affirm that l am exempt from the Contractor's LlaSPECIALCBtCUIT/M1SCnse Law for the
'�9 following reason.(Section 70115,liminess and Prolesabm Code:M " or 1 a r
OrLFu� countywhichrequl apert ttocomtruct,alter,bnprovede=lbh,orrepalr TEMP.MEIEROR POLE INST.ti
q'� .as anystrumm ptiorto its issuance,also requlresthe applicant for such permit to POWER
DEVICES
6 O file a signed statement that he U licensed pursuant to the provisions of the , t
3 Contrsesm's License law(Chapter 9(commencing with Sectbn 7000)of Divi-
I slon3ofthe Bustne dProfmse Code)orthathehexempttherefmmand SWIMMING POO - - + VALUATION
y.' the basis for the alleged exemption. Any violation of Section 7(315 by any R p t1J', tj
e'S applicantfora permitsubjeesthe applicant to a civil penalty of not more than OUTLEISSWITCI W FIX'I'UAES
ofive hundred dollars($.500. n
Q I,as owner of property, NEW RFSIDENIIALE ECTR '�1 - t F[. SfOW6S TYPE CONSTRUCTION
�. ❑ p perty,or my employees with wages as their sole
C Q compensatlon,willdothe work,andthe structure is not Intended or offered for °
5 O sa1e(Sec.7044,Business and Professhma Code:The Contractors Lirense Law `h
$$ does not apply to an owner of property who builds or improves thereorx and OCC.GROUP RES,UNITS
who docs such work hine elfor through hlsown employees,provided that such
Improvements are not Intended oroffered for sale.I(however,thebullding or TOTAL:
Improverrcnt h sold within oneycaro(wmpletion,thcowner-bu1W fir will have
t4t.lZurden of pmving that he did not wed or improve for purpose of sato.). QTY, PLUMBING P MIT FEE pfDo, NE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Pro(emiom Code: Z
The Contrectore License Taw does not apply to an owner of property who - ALTER-DRAIN&VENT WATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojecU with a
c-
,nlf+none)Ocensed pursuant to the Contractor's Licema Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. 0 &P C for this reason
• Owner Date DRAINS FLOOR ROOF,AREA,GOND. SAMTARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECE Pf N
01 hereby affirm that I have a certificate of consent to self-Insure,ora f. FIXTITRFS PFR TRM 32 / SCHOOL TAX Y N_
certificateofWork m'Compemationlro mnceoramdifk copythereof(Sec. RECE17TN
3800,Lab C.) GAS EA.SYSTEM.]INCL OUTLETS PARK FTSE Y N
Policy N NRECF3PT M
Nix GAS EA.SYSTM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy b herebyfurnished.the cit. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy h filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(fhlssection need not becompleted tithe permit la foromhundred dollars SEWER-SANITARY-STORM EA.200FL Date Recei t#
]artifyth
(5100)orf /E,ECTR ENERGYFEE Ythat in the per(omtimWATER HEATER W/VENT
ance.(the work for which this permit is
Issued, N—
I
—I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
O Applicant
^Compensation laws of Call(arnla.Date PAID
PP TO NEW RESIDENTIAL FILMS.
Z in NOIICEcome..LICt to the
after rs'Co thisCertificatecateof Exemption,you SQFT. Data Recei t#
F Code, wcomst fortctmthe Work en'such provisions
s Laborbe TOTAL:
WN Cale,you must forthwith comply with such provlsloos arthis permit shall be
j deemed revokes. BUILDING FEE
a 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I hereby affirrnthat there h a construction lending agency for the perform- �` ELECTRIC FEE
ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: a�
V O Lenders Nnme PLUMBING FEE
LLF Lenders Address QTY. MECHANICAL PERMIT FEE r
O W 1certify thatl have madthbapplicationand state thattheabove informationMECHANICAL FEE
1 iscone".I agree to comply with all city and county ordinances and&ate laws PERMIT ISSUANCE FEES PAID:
>. W mUting to building comtmctlogand herebyauthorice representative%.(this
1— Z city to enter upon the above.memloned property for inspection purposes. ALTERORADDTOMECH.
V — (We)agree to save,Ind emnlly an d keep harmlem the City of Cupertino Date Receipt#
against liabilities,pcigment,costs and expenses which may In any way accrue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
ago List said City in �gu n ce of the granting of this permit.
AIR HANDLING UNTI(OVFR 10000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUgr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7AR DOUS MATERIALS DISCLOSURE
Will the applica est or future wilding occupant store or ha nd Is harardous HEATING UNIT(TO 100,000 BT1n
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the Date Recei t#
I fealth and Safety Code Section 15537(1)7 HEATING UNIT(OVER 100,000 BTUs
F-11Yes 09 No TOTAL:
Will the applicant orfutum wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESLD) ISSUANCE DATE
which rout haaard...air contaminant as defined by the Bay Area Air pp/Rp
• lity Mangement District? BOILER-COMP(3HP OR 100,000 BTU))
Yea IxL��ats No
Q�jnhnve read the hnzardom matetinb requirement under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ( 1890
the California Health&Safety Code,Sectlont 25505,25533 and 25534.I
understand that lithe wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be mot
Prior to Lssuance of ifirate o(Oca
_ ( R� xx,,-4N r0� VV YY
Ownerorauth .icdagent Date ISSUED BY: V
TOTAL:
OFFICE COPY