20654 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY .
Building Project Identification PERMIT NO.
BuOdin Adrlrese: 20654
era V J11hone: Al'I'L1�110N hIJUMII IAL[JAIL
�1
71?& p
OF CUPERTINO-BUILDING DIVISION
ractors Name: Lic•NoAPPLICATION / PERMIT .
BUILDING-ELECTRICAL PLUMBINGMECHAMCAL CATEGORY CONTROL.N
•�' ArchitectEn91CVgN�SED
e LkNBUILDING PERMIT INFO
QTY ELECTR[C PERMIT ' FL•GAddress: PERMITISSUANCE IJV NT0.ACT00.'SU CW0.ATION I
I hereby affirm that l am licensed under provisions of Chapter 9(romncre APPIIANCFS�RESIDENfIAL JOB DE-SC
IngwlthSedion7000)ofl)ivlclon3oftheBuGnemand ProfekonsCode,andmy , - .0
license le In full sand d(. `e'N , z�3 PANELS „s O
Llanse Gla Lk.M a�Z` - r �'/wl �C/.. `a,
Date��� aMnd r Y✓`
0.CHITECT ECLARATION 701-I WO AMPS
a0 O I understand my plain shag be used ss public records OVER IOW AMPS SQ.FT.FLOOR AREA - $/`.Q.FT.
kn� Llansed Profeeslovl - SIGNS ELECTRICAL. -
1`n 6
OWNER-BUILDER DECLARATION1 hereby affirm -
n SPECIA CUIT/MISC
following..on.
thatSed Imii7 exempt from
a Contofinde UcereGy city he or
oo foliowingmyon.(Section7011.5,Businessdand,i.pmeo Code:Any city it
Fcountywhkh rcqulresa permilromrtract,alter improvgdemolbh,ormpair TEMP.MEN
POLE]
5 anysbudure pdortoits leeuance,also requiresthe applicant forsuch permit to
5 file a signed stateroom that he hi licensed pursuant to the provlslor of the POWER DE'VIC
Owl Commerce.License 1.w(Chapter 9(mmmendngwith Section 7000)ofDWI.
� 5 slon3 oHhe Buelneas and Profeeebiu Cade)orthat he Vexempt therc(romand SWIM G ITE - VALUATIC
O_ the basis for the alleged exemption..Any violation of Section 7011.5 by any UTLE ' D! D D D D l 0 O
applicant for a permit subjects the applicant to a civil penalty of not more than
$ live hundred dollen($500, NEW R AL STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employee.with wages as their sole
compensation,will clothe work and thestsudum k not Intended or offered for
O ule(Sec.7044,Business and Professions Code:The Contradoes Llanse law
�$ does nmapplytoan owrrof properly who builds crimprovn therms,and OCG GROIII' RES.UNITS
who dins such work hlmseff mthrough hie own employees,provided that such
improvements am not Intended or-offered for sale.It however the building or TOT
Improvement Lseoldwlthlnamyearofcamplmlb theowner-buaderwlll have
the burden of proving that he did not build or improve for purpose of saleJ, QTY•n..1N
P 'FEE FLOOD ZONE APN
u L as owner of the property,zm exclusively contracting with licensed contractors to mnstrvd the project(Sec.7044,Business end Professions CodcThe Comrade,.Liar.law does not apply to an owner of property who -WATEkaX
builds or Improves thereon,andwho contram far such plojeda with e
cg1B[ado(s)Bared pursuant ro the Contractors License Law. DEVICE FEE SUMMARY
I am exempt under Sec' B&P C for this reasonOUTSIDE FFES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP .. SCHOOL TA% Y N
I hereby e(flrm that I have a a"ifleste of consent to self-Imeum,or a RFOEII'f N
certlflcateo(Worknri Comperatlon lrumcceora certified copy thererf(Sce. GAS PA.SYSIT'M-1 WC.40U71.E15 PARK FEE .Y N
38 W, C
1'011 RECRIPT N .
��' /yy�—sem///�J��/� GAS EA.SYSTEM-OVER Co�any .i� '>r• L /F gU1LU1NG DI VI510NFE[S
Ce"P,i! yI TILL GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�cenlnedmpy�nlaawltntnedtywpedlonaivl.inn. -
CERTIFICATE OF E(EMPTION FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 7WFT Date Recei t(f
(This xdlon need nO M completed](the permit V forone hundred dollen
(S1W)orlesa) WATER HEATER W%VENT/FTECTR ENERGY FEE Y N_
I certify that in the per(ornuna of the work for which this penult is lasued,
I shall not employ any proem In any manner m se to become subject to the WATER SYSTEM/TREATING ,
WorkeWCompessstlonlawaof Ca Bfomia.Data PAID ' -
C1 Z ApplicaNOTICE NEW RESIDENTIAL PLMB. :OFT. Date Recei tB
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Comperatlon peovlsior m the Labor TOTAL:
4/)
Code,you=at forthwith mmplywith such provislororthe permit shall he U . OD
deemed revoked. 1
W CONSTRUCTION LENDING AGENCY. - SEISMIC FEE
Ihereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE a
Z ao,o.fthe work for which this permit k issued(See.3097,Civ.CJ - TOTAL: :� 1 00 _
U O Lender's N. PLUMBING FEE 0
IL 1— )enare.Adaress QTY. MECHANICAL PERMIT FEE' MECHANICALFEE
OW I cerilythat l havereadthisapplicatlonand Gate that theabove m"anndaon
C Iecorred.Iagrm to comply with all cityand muntyordlnancesand Gate law. PERMIT ISSUANCE - (�u FEES PAID:
} rn
llding mrtmdion,end hereby authorize representativn of this
>. Zcpong constvcmentbnedproperlyfor mizereNonptivea o. ALTERORADDTOMECH. Date Recei LNa to save,inemnl an d keep harmless the City of Cupertino Ptlea,judg cat ea saes Aidch mayIanyw ace AIR HANDLING[IMT(TO 10,000 CPM) SUBTOTAL: Vatty In equ of ti ng of thio permit
` ��� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
pplionto rad WD a IXHADS'PHOOD(W/DUCT) CONSTRUCTION TAX PAID:
NAZA OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Gore or handle hazardous HFATINGUMT(TO1W,000BTU) - Date Recei t#
nuterula.defsedbythe Cupertino Mu.idpal Cod,Ch.pterg.IZ.a dthe -
Hcahhand Sdety Codi Sectlon75537(a)7 HEATING UNIT(OVER 100,000 BTU - TOTAL: 3 _k
❑Yes No ..
Will theapplicantoprumbullding..p.cat u.sequipment ordevicas VFNDLAT'ION PAN(SINGLE RESID) ISS ATE
wh lch emit hazardous air contaminants as deft red by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,D(0 BTU 1' 'i
4 Ye, No 4� L V I� lyyV
have readthehaza o...teriaisrequimmnlsunderChapter6.95of BOMER-COMP(OVER 100,00)BN) JUL
the Califomk Health&Safety Code,Section 75505,75533 and 75534, I
understand that lithe building does not arrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.PT.
resporibility to notify the occupant of the requirements which must be met of Cu
prior to issuance of a Certificate of Occupancy,
Ownermauthodzed agent Date TOTAL: ISSUEDBY:
�(�rn
OFFICE COPY