20563 (2) ArrLIUAN I TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PER.MITNO.
Building Address: 20563
Ib3� �Ita3 Cre�e� P l_
.p I� one:
Totm(me. fi Ike cJ�U 98 110b CITY OF CUPERTINO-BUILDING DIVISION
Conatsra_etersName, ueNn: APPLICATION 1 PERMIT
,R'N�� �" N O BULDINGELECTRICALPLUMBINGMECHAMCAL CATS O CONTROL p
Architet/Englneee Lie No:
L QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: M _ w)&+iijGTr ERMTISSUANCli ❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment, APPLIANCES-RESIDENITAL JOB DESCRIPTION
Ing Moth Setion7000)Of DiAsion3ofthe BuenenandPmfessfon'Code,and my
license is In(u nd effect PANELS W�
Date Cls®V46-Llc N r ,,,,i paC�
Date. 14�C HI ECTSraC-1'ctLARAA`-"Ca_ItJ_1`v�P .
ARCHITEeuSD DECLARATION OVER0O AMPS
ODDAM
q OVER]000 AMPS f/SQ.TT.
q��vv ot0 Z [underetand my phm ehaB be used n public remrda ' - SQ,IT.FLOOR AREA
k d� Licensed Professional SIGNS ELECTRICAL
6OWNER-BUILDER DECLARATION 9'ECIALCBtCUT/MISC
Z. 4 Ihercbyafflmn that l am exemptfrom the Contractor's License Law for the
ppppp fallowing reason.(Setion 7031.5,Business and Professions Code:Any city or
0 i'iy county which requires a permit to cetutrut,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
5
33 anya suture tate e t W t he is lice re d pursuant
to the provisions
of t e POWER DEVICES
O O. Ole a`Igoe. kens statement that he V licensed punuant to the pro 7000) of the
Contractor.ofthe Hughes Lw rodeaser9(comme thmheding hSetW therefof Divi- SWLMAINC]VIOL ELECTRIC
tgenbasis for
the aIle a dProtmlon. Any violation bSodion herefromany - VALUATION '
the I for the alleged exemption. Any violation o!Section 703 L5 by any
6X ape hundred delta.tsubjetlstheappBcant loo civil pesuityofnt nnret)an OVILETSSWIICIiESflXTURES
five I,as o ner of the property,
ro NEW RESIDENTIAL ELECTR FT.
MI,as will oche w0etty,arhe employees isswllhended r offered for ES TYPE CONSTRICTION'
E mmpematlon,willdothsworkandthesCde:Ths ContendesLimfere.(or
Y O sale(Bet. ppy Business and f property
Code:The or imptars Llmem hw
�$ doneassucytoanowner ofprough whonerniarimprovnted thatand OCCGROUP RES.UNITS
who don eats amrkhlmse intended
hlsownemp,howeprovidedth mash
improvementsarenet Intended earodoo forsak.IL howeveq thebulldingve TOTAL
Improvement issold within omyearo(compinion,the owner-bullderwlll have
tfte,,hurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT E FLOOD TONE APN
Lj L as owner of the property,am exclusively contracting with licensed pFltMIi ISSUANCE
contractors toconstruct the project(Sm 7044,Business and Profession Code:
The Contractor's License Law does oat apply to an owner of property who ALTER DRAW A VENT WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojecha with a
ry0tr-tlar(s)lforsed punuant to the Contractor.License Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE
U I am exempt under Sec. 0 k P C for this reason OUTSI UP FEES
Owner - DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION TEXTURES-PER.TRAP OOL TAX Y N
❑I hereby a((Irm that 1 have a cedifiate of consent to self-Inwre,ora RECEIIPT M
cenl(late ofWorkeri CQomperieatuiggqqn 1ir,snceara cetl(hd copythereo((Sec. GAS,EA.SYSTEM-1 INCA OUTLETS FARRIER Y N
3800,lab CJ11� 1� I 1 7 'RIiCEI'1'p
Co Y s T GAS EA.SYSTEM-OVER 4(EA)
m
{'n -Nle' BUILDING DIVISION FEES
Mcetmea ropy k nk
tlfl cop V l byd witht� sheer.he styIrupetmn aim.Ion. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
t
CERTIHCATEOFENEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(TMsaectlon neednut be tompinM lithe permit is for
un
e reldroddollars SEWERSANITARY-S[ORM EA.3001'7. Date Recei t#
(f1I ordifess.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Illcuy that Nthe performance
Any
the mwok forwmcbeco become
esubjec koros —
1 Whale not employ any perws In any manner w n m become subject to the WATER SYSTEM/TREATING , 0 Q
worker:CompenaBon laws of Call(ornk. Date PAID
—
z
Z Applicant
Z O NOTICETO MPLICAtothe after omper dim,pro ar Esemptmn,you
NEW RESIDENTIAL PLMB. SQFT. Date Rece1 t#
should eyon,oma aubjAct rthwit ou Worksss'Comp roviskma.rtispervisions it s Lobar TOTAL:
_N Casae. at forthwith comply with such provision orthb permit shall be IL IN
� > deemed revoked. G FEE
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirm that there laa comtsunion lending agency for the perform TOTAL: p ELECTRIC FEE
:3Z ance ofthe workfor which this permit kdsund(Sec.3097,C1v.C.) .(�
Tqlar
02 Lender;Nam PLUMBING FEE
IL 1— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceditythatlhave read lhkappllationand aatethat(heabova lnformatloe
1 is correct.l agree to comply with all city and county ordinances and stale laws PERMIT ISSUANCE
FEES PAID:
} W. relating to building corutructIon,and herebyauthorixempresenlativnofthis
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH. Date RCCe1Pt#
V (We)agree to save,Indemnify an d keep harmless the City of Cu pet Ino -
agalnstBabllities,judgments,ones and expenses which may In any way Acwe AIR HA NOLING UNIT(To 10,ODO CFM) SUBTOTAL:
agairut uld Cetyl con enceo he antln Ihls permit. AIR HANDLING UMT(OVER I O,WO CTM) CONSTRUCTION TAX
S re. App s mono Data EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA S ISCLOSURE
Til cappliant or future building oau score orbandleh.rdous HEATING UNIT(TO I00,000 BTU
mate a as defined by the
but
Municipal Code,Chapter 9.17,and the _ Date Reaei t# _
Hnithand Safety Cade Sectlon75532(x)7 HEATING UNIT(OVER 100,006 BTU TOTAL, �-
0 YnM NO
Wllltheappiicant orfuturebulldhRoccupantuseequlpment ordevices VENTILATION FAN(SINCLE RESID) ANCE DATE
which emit harardeus air contamiwnta as defined by the Bay Area Air ®!
Quality Management D❑lsWt7 BOILER-COMP OHP OR 100,000 BTU)
P4 Yes m. N No j
h nla ealth a o�mode,b tions 2mennundeAnd 25534. 1 of BOILER-COMP(OVOt 100,000 BTU) -VI 2 19904
- the Glflornla Hcalih&Sa! Code,Sections 75505,ZS533 and 15534. 1 ( L/
understand that if the building don not wrrcntly have a tenant,that It is my NEW RESIDENTIAL MECH. SQFr.
responsibility to notify the occupant of the requirements which must be met 014
prior to Lssuanm of a Certificate of0aupancy.
Owner or authorised agent Date ISSUED BY:�1'i''�VJ s*--NtW�+CI
70TAL:
lu OFFICE COPY