20891 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POIVT EAI(SNLY
building Project Identification PERMIT NO.
Building Address: 20891 O^^1
I 0z u Lf- >✓M PI R Z �✓Z— ��PXfi T h o _ C/9- G �}J(.yJ
nems ame: A h e: A
JUQ 17,3 / -0 , CITY OF CUPERTINO-BUILDING DIVISION 6-4 "o
(a,.�� �Q
cmntra o/aJ�amel:-} Lk.Nm APPLICATION / PERMIT V-4 L-o
Lk.No: BUILDING-ELECTRICAL-PLUMBINGMFE NICAL CATEGORY CONTROL Y
ArchllM/ gine&&
M I 2 Pw
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: PERMITISSUANCE Co
LICENSED CONTRACTOR'S DECLARATION 1
Ihercbyaffirm that l ant licensed under provisions of Chapter9(commenc- APPLIANCFS-RESIDENTIAL JOB DESCRII''IfON ^
ingwith Sedion7000)oMD slon3ufthe Businnsand PmfesslnnsCode,and r'7 'Pit-apv-\a .+.vim
Bums,Is In full fo)ce and effect. PANELS
License Claw Lk.M
Date Contractor —UP TO 2DOAHM
ARCHITECPS DECLARATION 201.1000AMPS
q�u aO Zp I understand my plans shall bs used as public reuuds. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FF.
c Licensed Professional SIGNSELECTRICAL
^eN S'U }'ti -1l.-q-L
OWNER-HOLDER DECLARAITON SPECIALCIRCUIT/MLSC l/, 1�i1Ol J
02�: Ihercbyaffir (Ses tin731.5,Bfro ossa Contractors License law fort he 'T�l
qq following reason.(Section 7031.5,8ualness and Professbna Code:My city or
t'u) rountywhich requlres a psrmRtoconrud,alter,Improve,demollsh,or repair TEMP.METER OR POLE INST. �O, (,(J
anystmumpdortollsiswance,al requlrntheapplicantforsuchpermitto
POWER DEVICES
3 d� file a signed License
that he(Chapter licensed pursuant it the provisions f Me
w Con3ofthe Business
and Professions
encingorthat he is with exempt
ection 70M)mpttherefof Divi- SWIMMING POOL ELECTRIC
O skbasis for the
Code orlationf exempt therefrom and VALUATION
the lucent for the alleged exemption. Anyviolationtolacivi of Section nor m re any
appluctnt fordred apermRaubjects the applicant too civil penalty of rarer more than OUTLETSSW[TCHESHXTURES 1 16 8'la .8a
c.p� live Nuns owner
the 00). NEW RESIDENTIAL ELECIR SQ,FF,
0.. ❑I,as owner of the property,or my employees with wages as their sole STORIES =CONSTRUCTION
�7< compensation,will dothe work and thestmume is not intended or offered for .r
x D
In(Sec.7014,Business and Professmos Code:The Contractors License Law 1
don not apply to an owner a property who builds or improves thereon,and 812 OCC.GROUP RIS.—UNITS
CC who doessuchworkhimlf
seorthmugh Msown employees,provided thatsucM
improvements arenot intended proffered for role.IL howeveq thebuilding or TOTAL:
improvement issold within oneyearofcompletion,the owner-bullderwill have s
W� '� of proving that he did opt bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FIADDZONE APN
�Q L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /'1
t ctors to ronstruct the project(Sec.7044,Business and Prnfemions Code: 1,y
Tic Contractor's License law don not apply to an owner of property who ALTER-DRAIN k VEM-WATER(EA)
Wilds or Improve thereon,and who contracts for such projects with a
c%4actoKa)licensed pursuant to the Contractor'&License FEE SUMMARY Law. BACK FLOW PROTECT.DEVICE
Lj 1 am exempt under Sec B k P C for thin mason
OUTSIDE
Owner Dale DRAT S I#AIBFq, ON1� SA ARY RECEIPT If
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self-Inwre,ora I'IXv" BR TAP SCH LTA% Y N
wnifiateofWorkers'Comps.tionlnsurannoracenlfWmpythereof(Sec. i� _ RECEPr#
3800,Lab C.) GAS .I INC_4Ogng S (..i PARKFEE Y_ N_
Policy N / REC®rT p
Cam any GAS .SY -0 4(EA) BUILDING DIVISION FEES
�Cenined copy is hereby furnished. GR DUSTRL W _ P NCHECK FEE
❑Certified copy is filed with the city Inspection division. -
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE
Rhbsectlon need not becompleted nthepermit isforone hundred dollars SEWER-SANITARY-STORM EA.20CFT. Date Receipt#
(SII unit that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icenmthatothe performanceof the work wo toh(his wbjis Issued, —
1 shall nm ompioy any person f any manner at m to berorre subject to the
Worken Cempensatlon Laws of California.Date WATER SYSTEM/TRLA7ING PAID
Applicant
Z O NOTICE TO APPLICANT.IL after makingthb Ceniflale of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recef t#
Fshould become subject to the Workers'Compensation provisions of the Labor
N Code,you must forthwith comply with such provisions orthispTOTAL:
permit S 2
WBUILDING FEE xQo
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iofthe work for that them Lsaconstruction aguee(Sec. gencyf.C.) perform ELECTRIC FEE ,'
7 Z once of the workforwhkhthb permit utawed(Sec.3097,CIv.CJ
TOTAL: �1'2
02
Lender's PLUMBING FEE L
LL H lander.Addmm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenlfythatlhavereadthuappnation and matethat lheabovelnformation
a brorrect.l agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE 17-00 FEESPAID:
} W city to gtobulon t mruwction,andhembyatyor In rcpresentativn olthis
F Z cityW)aree to ave,he Indemnify an
propeharml Inspection purpose&. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify an d keep harMess the City of Cupertino Date ReCCiPt#
against liabilities,Ndgrnents,costsand expenses which may In anywayaccrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL-against said City in consequence of the granting of this pe7i/
a AIR HANDLING UhTT(OVER 10,000CFM) CONSTRUCTION TAX
�r/9 fl _
,Sign,ffareof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ��@@
Will the applicant or future building occupant store or handle harardom HEATING UNIT(TO 100,000 BTU)
mmnerblas dented by the Cupertino Municipal Code,Chapter 933 and the _ Date ReceI tit �Za9-
IiallhandSaletyC Ion 2S532(a)7 HEATING UNIT(OVER IDg000 BTU) TOTAL: U
❑
Will
'�'J,No
Will the appllant r mrebuilding occupant use equlprrcnt ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emJt harardo umntamiruntsas defined bythe Bay Arca Air
W Illy Mawgement trict7 BOILER-COMP PHPOR 1W,IXq BTU)
4Y.
havereadthe bavpuswtonal,mquirmntsunderChapter6.95of BOILER-COMP(OVER]WppBTU)
the Caifornla Health Safety Code,Sectims25S05,25S33 and 25534.1 oU�
understandthatilthebuildingdoesnotamentlyhaveatenanpIs
thali( my NEW RESIDENTIAL MECH. FT.
responsibility to notify the oaupant of the mquiremenls which mus(be mot _
prior to Issuance of Certificate of Occur �ancy. 4 j"1
/ L
Ow eroraWholulea ent Data
TOTAL: ISSUED BY:
OFFICE COPY