20961 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: q 20961 0 /'I^ 1
7°J' C3I C `a.-y0 C l Q- G �~l FVt I
hone: A A
'nr nme:� ILLh` �l ZS3^�oS�3 CITY OF CUPERTINO-BUILDING DIVISIONl O�
c°ntraio aNa Lie. APPLICATION /PERMIT V {_ l
a+-1 , BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
APMted/Engineer. I _ n Lk.NJA{:
� LV11.J '� �A lk L RCE 1'1 ai- `QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:I-Z — Y kiee C PERMITISSUANCE UU El El
DECLARATION ,
I hereby affirm that l am licensed under provisions of Cha pter 9(comment APPLIANCES-RESIDENTIAL JOB DFSCCYJ
L2Q'D
Ingwlth Sedtan7000)of Division3ofthe Businessand ProfeselonsCode,and my I ••I\yv,
license's'n el PANELS S're�G
Limn Cl. L'N
Datej +�! Contractor UP TO 200 AMPS
ARCHITECTS ECLARATION 201-IOOOAMPS
X, I understand my plans shall bo u as public records OVER 1000 AMPS SQ.IT.FLOOR AREA •$/SQ.Fl.
pO
(C) Licensed Professional SIGNS ELECTRICAL
WB
w ONER- UILDER DECLARATION�"na SP[CIAL CIRCNT/MISC
k• Ihebya(Rrtnthat]am exempt from the Cont ractorsLkense Law for the '
7p 9 3 follrcowing reason.(Section 7031.5,Business and Professions Code:Any city or TFMp,METER OR POLE INST.
u9 countywhich requiresa perruttoconstnd,alter,improve,demolish,drmpair
�4Y�d anystm=mpdortoita mance,aWmquirestheappbantforsuchpermitto TOWER DEVICES
C c, file a signed statement that he is licensed pursuant to the Pnw a,ms of the -
�j Contractors License law(Chapter 9(comments with Section 7000)of DWI-iii B SWIMMING IDOL ELECTRIC
O sldn3 df the Buslnessand Professloa Corte)orthatheisexem fberefromand VALUATION
P S^ the basis for the alleged exemption. Any violation of 5n tion not 1.5 by any OUTLEISSWITCHFSFIXTURFS �' ^�
five edred permit subjects the appiicamtoa dull penalty of not room than
�u five n s owns of the pro
�.g. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
as owner of the property,or he employees with wages r!herr sol.for CZCl pccc.7on,wiflelothe Business and kand thes Code;e is The
Intended°License
Law
5 Cl le(Sec.apply
to an ow and Professions Code:The Contractors Lirense Law
pjSQ whododoes t applytorn owner ofpmpedywho
anemsorlmproves ovided that such
OCC.GROUT' RES.UNITS
EE wprovemes ach am not attended hrwgh his owae.If,hoes,p ,thebuhatsucr .
improvements sudwithinded carofco plello.theownvep deer ill have TOTAL:
Improvement issoid within oneyearofcompldld,the owner-bullderwlll have
th�e drden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONEAPN
"L as owner of the property,am exclusively comracung wan ams— PERMIT ISSUA E
contractors to construct the project(Sec.7094,Business and Professions Code:
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN -WATER(EA)
bu'Ids or improves thereon,and who contncta for such p(ojects with a
on
actor(s)licensed pursuant to the Contractors License Law. gAQC FLOW PRO .DEVIL FEE SUMMARY
u 1 am exempt under Sec. B&P C'for this rcesonn'TTq.'1r VS
NS ROOF,A ND. SANITARY Y_ N_
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION TRAP SCHOOL TAX Y N
❑i hereby&!flan that I have a certificate of consent to self4.oure,or RECEB'f M
cer'flateofworkemi Compensationlns nncewamdifkd opytheno((Sec. C STEM- . PARK FEE Y_ N_
3500,lab CJ C4 RECEIPT N
Polity p
Com any �MGREASE
R ) - BUILDING DI VISION FEES
�certined mpyisnercby mm'aned.. STEI R PLANCHGCK FEE
❑
Certified copy is filed with the city inspection d]vision. `
CERTIFICATE OF EXEMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE RM FA. Dale Recei !#
((hissection need nut be completed tithe permit is forone hundred dollars
(4100)wless.) WATER HFATERW/VENT/EFL ENERGYFEE Y_ N_
I certify that In the performance of the work(orwhich this permit Is bauM,
1 shall not employ any person in any manner so as to become subject to the WATERSYSTEM/TREATING
Workers'Compensation laws of Callfomla. Date PAID
z Z NOTICApplicaETOE NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
Z O Nhcudb co MPLICt tothe orlunafter kingthis Certificate is Exemption,the
shmid become subject m the Workers'Compensation provisions°(the Labor TOTAL:
CCfD Cod,you at forthwith comply with such provisions or this permit hall be BUILDING FEE
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the pedorm- TOTAL: ELECTRIC FEE
Z ante of the work for which this permit is issued(See3097,Civ.C.)
(•) O Lerdw•s Name - PLUMBING FEE
F— Lenders Address QTY. MECHANICAL PERMIT FEE
OW 1certlfythat l haveread this application and aatethat theobovelnformation MECHANICAL FEE
1 iscer et.Iagsm to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to bul:BtoZ construction,and hereby authumm representatives of this
N
city to enter upon the above-mentioned property foe Inspection purposes... ALTER OR ADD TO MECH.
Z
(We)agree is save,indemnity and keep harmless the City re Date Receipt#
W
V agatllabllltlea,' dbcosts eta and expenses which may in anywayaay!cga AIA HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against acid ue o t gra esti ,Tibia pe it.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
S natured( ppRant/ConIraidr , Dat EXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUBM E ALS DISCLOSURE
Wllltheappliantortuturebull Ing occupant store or handle haaxrdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Flealth and Safety Cod ion 25532(a)7 HEATING UNIT(OVER 100,(X0 BTU) � TOTAL:
❑Yes No
Wllltheappliant o to re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) CE DATE
which emit hazardous Ir contaminants as defined by the Bay Area Air
Quality Maoagdment istrlctl'• BOILER-COMP DHP OR 1MM BTU)
Yes
haveread;hehi
ty CWc,acci Ion 2WS, 5533 and 25534.
of BOILER-COMP(OVEt100,ON BN) / 111. 311990
the Califon that if thein fayCoda of currently have
a tendt,that ] f 4SM
urdentarlitytoftilytheoccapauilding doesnot
meats hichrehatbisiny NEW RESIDEMTAL MECIi. SQ.FT.
responsibllitytonalfythe occvpa !°fibs rcquircmentswhlch must be core!
pdorto Lssua f dllka parry.
ncr dFauthoriaxi agent Date t TOTAL: ISSUEDBY:
OFFICE COPY