20885 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buudln Wlca
Project ldention PERMIT NO.
Building Ado:, 20885
Phone:
/ri _ CITY OF CUPERTINO-BUILDINGDIVISION p' /j2
Con o 3
Name: 1u N APPLICATION / PERMIT 0 ' T "�Q
d— BUIIAI aG TRICALPLUMBINGMFGHAMCAL CATEGORY CONTROL 9
ArchkM/Englruer: Be Nu
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PFTth11T1$UANCI� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrtnthatlam lkmsed undernderprwWons of Chapter9(tammnc A13ef1ANC6RE51DEN]lAL ) B DESCROM N
Ingwlth to life ardeldon7 dthe Budmmand Pro(eulonsCode,and /,
Lic nm b In fufl life d d(ed. PANES
Daruc Clam cmd '9' '
Date ri� CoMnCor
zl ARCHITECTS C RATION 1-1 AMI"''
xp Iarderstam my phroahau be used es public records. OVERIODOAMT'S SQ.FT.FLOOR AREA S/SQ.FT.
Lianacd Prdembnal SIGNS ELECTRICAL
<<G
�6 OWNERe"mpt ER DECLARATION SPECIAL CB4C(JIT/hLLSC
Z I,�� Ihemby afflrmthatiam e:e5,Bust cease Codrxmrs Lkxrue Aoydtthe
f-UnwIpppQ tuortyingmawn.ireala mind to,BuemMm tProp®b C ld h,ydtyor
K F'� musty which rcqubnapemdt tomrWm4dtcr,Improve,drmolbh,ormpav IFMP.METEt ORIOLE WST.
'� anystrvctum prfmto lb bruarce,alwrequlmstheappBant(m such permBto
file a signed statement that he as 1111sed pueuan[to the provbbns of the TOWER DEVICES -
�9��1- Contnnor's License Law(Chapter 9(mmmenMg whin Sedbn 700Bd DWI- SWIMMING POOL ELECTRIC
.J7 ebn3 ofthe Business and Pro(embv Cade)orthat he b exempt thea6omard VALUATION
K' the basis for the a11egM exemption. Any violation of Seekm MIS by any OZ)77.E(S,MT.rcFh5�F1)t111R6
appBant fora permit subjects the appB t to a dull pensicy d not room tha o pO
(ivS,hundred
della.(S 0). NEW AENTIAL ELEGTR SQPI'. SNW6 TYPE CONSTRUCTION
u1,as owner of tit property,or my employees with wages as tkir wk F�
C mmpe—Lon,will do the workand the arudum is not Intended or offered for
$' p ale pec.7014,Business and Prdembv Code:The Contractor.License Taw
$$ does not a pply to an owner of property who bull"or improves tkrron,and OCC.GROUP RFS UNITS
d..&work himself or through his own employees,provided that such
Imprvvemenis art not intended oroffered fcreak.It however,the building or TOTAL:
Improvnnrrd beold wfth lo omyeurdcmupldb,tk owner W Bder wlil have
t rdenofpmwngthohedidn ildorimpma forpurpoeeofeale.). QTY. PLUMBING PERMIT FEE
G u owner d the property,am evcluslvely contracting with Iberued FLOOD TONE APN
contractors to corstmd the project(See 7044,Businem and professions Code: PERMIT ISSUANCE
The Conmdore License law does rat apply to an owner of property who ,Q -DRAW k VFNf-WATER(EA)
builds or Improves thereon, and who contnm m fee such Mjewith
cpIrse ou(s)Banned pursuant to the Cmrvart&s License law. FEE SUMMARY
L_JI am exempt under Sec B 4 P C for this reason BACK FLAW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEI'Ts
WORKMAN I haw a certificate
eument TION FTXTURFS PER TRAP Sp{pp,TAX Y— N
❑[hereby affirm that 1 have a eertllhte d cmxn<to self-insure,m
rtiofworken Cwnperurtimu lruunnce as led repytheeof pec. RIGI]I'I'I
afiate
3800.Lab C) 70 GAS F.A.
.BYSTFM-1 C40I7ILEI5 PARK FEE Y_ N—
com1 i GAS EA.SYSTMOVER4(EA) RECEB'I♦
Y BUILDING DIVISION FEES
IC 1r_d cop he mlah
Lr�Jc�-�.,.IBed copy b filed with[be
elty Inspection dlv oo. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONc= & eft INSURANCE SEW Et-SANRARY STORM EA x10FT Date Rcoci tit
(Thio uHbn need nd W compined H tk pemdt b froom hundred dollars
fA O)
Ia - WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
rtily yth that Nthe perfomuna o/tk work(orwNditMs pemdtbblued, —
I ehaR na employ any person In any runner w as to become subjed to the WATER SYSTEM/TREATING,
Wmkmatlonlaws of California.DatePAID
'Compena
O Z ApplicantNEW RFSIDI7J'ITAL I'LMB. SQ}T. Date Rc i tit
Z NOTICE TO APPLICANT-If,after making this CerHfiate of Exemption,you
Nshould)xnome subfcd to the Worken'Compemrtbn provision of the Labor TOTAL
_ Code,you must forthwith counply with such proNsbrte or this pc mut shank
LU ] deemed revoked. I 00
LU
G CONSTRUCTION LENDLNGAG6.NCY SEISMIC FE
I hemby a(Orm tFuttkrt bamrwmdimu lending agcruy In theperform ELECTRIC FEE
Z anm of the work for which this permh b Issued(Sm,309771,C.) TOTAL
O lenders Name PLUMBING FEE
LL ~ Lenders Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W IartBythatlhawreadthbappBatlonardstatethrttheabovelnformation
R bcorrect.lagr tocomwplyhaudtyardmuntyordln maanda rev we PERMRLSSUANCE FEES PAID:
>_ N rdingtobulldingmmtmu maMd rebyautharir mpnsenUtiveaofthh
L_ = cuty to enter upon the above-mentbrcd property for wpeetlon purpose. ALTER OR ADDEO MECH.grDatC RCCeIp til
— (We)aee to sae,Indemnify an d keep M
p harem Gu
the City of pertlno
against Bab ,pdgrrcde,mstsard cxpenseswivuhmaylnanywayacvue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
ago tea I,,locmulwue of tingdthb it
` AIRHANDUNIGUNTT(OVERl0000 CFM) CONSTRUCTION TAX
oar puant/eantmdaDate EXHAUST HOOD IW/DUCES CONSTRUCTION TAX PAID
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant nom or handle harardous HFATWG UNIT(TO 10LODD BTU) Date RCCCI ted
material as deflned by the Cupertino Municipal Code,Chapter 9.17,and the
Ff,Ahy.M Afety CodZ, ,dbn=(a)7 HEATWG UNIT(OVER iW,000 BTU) TOTAL:
9V Yes `-1`pP'I-W
Illthee -ndou future Wilding oavpwtuby the Ba Are, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whicheMthacmerusairtsudeflrcd by the Bay Arca Ab
Qu+Iky Mavgemeru Distrito? BORER-ODMP pl-B'OR 100,000
o o k /CJI
i love re ad the hex wemHeriab requimmenb under Chapter 6.95 of BOILEER-COMP(OVER 100,000 BTU)
tk CaBnl
fera Health Salary Cad,Sedbiu25505,2W3and75534.I ,'1 ,t^ot
understand that If the Woes rre
llding dnot cuntly have a tenant that it b ery NEW RESIDEN77ALMECH. SQFT Uu 199o t
repons to naBy the pant dtk nqulmrrcNa which murtk met '
rbc to rax da Cert "LL
pansy. �� M
_tw -i3-� UJ ►
Tor ohcvivd agent Date
TOTAL: ISSUED BY:��L
OFFICE COPY