20561 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
I
Building Project Identification
Building Address:
865-1 kv_KV06,
PFLWTNO.
20561
none a-. Phone
,e. VY VV"(,j v" e..ZS B 0(
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
APP0cXTR5K3I399IrrAr =A
C O
Contraeton.Name: Lie. No.
CATEGORY
BUILDING PERMIT INFO
BLDINGELECTRICALPLUMBING-MECIIAMCAL
UI
Architect/Ggineer. Lie. N.
Lee1 r
J `i—
Qn ELECTRIC PERMIT FEE
PERh9TISSUANCE
Address:
D E D
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commere
APPLIANCES -RESIDENTIAL
]OB DESCRIPTION
PANELS
Ing with Section 7000) of Division 3 ofthe Buslnessand Professionacode, and my
license is in full force and affect.
Class, Lk. N
3
Data
Date Contractor
ARCHITGCTSDECLARATION
[understand my phnashall Wused as public records
1
00 AMPS
OVEROVER 1000 AMPS /
SQ. Fr. FLOOR AREA
$/SQ. FT.
/
ISIGNS ELECTRICAL 1 '
Licensed Pedessloral
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
SPECIAL CIRCUIT/MIEC
TEMP. METER OR POLE INST.
['OWER DEVICES �
following reason.(Section 70315, Business and Professions Code: Any city or
my which requires a permit to construct, alter, Improve, demolish, or repair
any structure prior to its Issuance, also requires the a ppllcant for such permit to
floe a signed statement that he V licensedor pursuant to the provisions of the
Law refesser9(comnrndng withxemptthection 00)of Davi-
g. 3ofthe Business
slon3of the Business and ProfessionsCode)orthat hekexempt therefromand
the bast+ for the alleged exemption. Any violation of Section 7mt.5 by eny
applicant fora per..it.ubjets the applicant to a civil penaltyor not marc then
five hundred dollars ($.500).
JKI, as owner of the property, or my employees with wages as their sok
compereatlon,willdo the work, and thesuucham is not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors I.Imme Law
does net apply to an owner of property who Wilds or improves thereon,and
who does such work himself or through hlsown employees, provided that such
Improvements arc not Intended oroffered for sale. If, howevcp the building or
Yet
I
S_
CS7 F-
SWIMMING POOL FIE ,C
OUTLE SWITCI F FIXTURZS I
-: —I—
t
NEW RESIDENTIAL EI[.FGTR / $Q.FT. 3
1 % /
V�CQ)LUA�N
s r-�
6
TYPE CONSTRUCTION
OCC.GROUP
RES. UNITS
s
TOTAL:
Improvement Is sold within one year ofcompltlon, the owner-bullderwlll have
t"nianof proving that he did not Wild orimprove for purpose o(sale.).
"L as owner of the property, am exclusively mntracung with Ikensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
QTY. PLUMB[ PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
Ile Contractor's Llcenae Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojects with a
Cgfft ictor(s) Bcenaed pursuant to the Contractors License Law.
IJ 1 aryaxenpgsunder Sec. B & P C for this reason
ALTER -DRAIN & VENT 5 ATTR (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
'
DRAINS FLOOR ROOF, ARG, CONTI.
SANITARY Y_ N_
RECEITM
�( 11 ` / 4.��
Owner Data '� 1 `-7 B
WORIQrIAN COMPENSATION DECLARATION
MRES.
❑7 hereby affirm that I have a certlleste of consent to self -Insure, ora
E
reniRcateof Worken'Compereatlon Insurance ora certified copythercof(Sec.
3800, Lab C.)
PER
FIXRECEIPT
SCIT(pLTA% Y_ N_
N
GAS F.A. SYSTEM -1 MC4 OUTLETS
PARK FEE Y N
RECEIPT N
Ce X
Ce any
GAS G. SYSTEd-OVER
BUILDING DIVISION FEES
ffCenmedcopy L+ hereby. fumished.
Certified copy is filed with the city inspection division.
_
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANC14ECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID /�]a
SEWER-SANITARY-SMRMFA 2CCFT
COMPENSATION INSURANCE
(This section need not be completed if the permit isfw ore hundred dollars
($100)orless.)WATER
I certify that In the performance of the work forwhlch this permit Is issued,
Date ReCCI [71
HEATER w/VEM'/F1.ECTR
ENERGY FEE Y_ N_
WA.f.QtSYS.fEM/.I.RFA.I7NG
1 shall not employ any person many manner.o ++..ss to become e�bk Ito the
Wmken'Compemaauon Law..f PIlfmmia. Dateb— t L— Y G
Applies. *1 4- wIr ki zy. ... ...
PAID
Date Reed tq
NEWRMI)ENTIALPLMe. sQtT.
NOTICET MPS LICANT::If,after making this Certificate of Exemption, you
should become subject to the Workers'Compensation provisions of the Labor
TOTAL:
BUILDING E .00
Code, you must forthwith comply with such provisions orthk pemdt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE s
I hereby affirm that there is a construction lending agency for the perform,
an¢ of the work for which this permit is issued (Sec. 3097, CIv.C.)
Icmdera Name
Lender's Address
I cedifythatl have readthb applicationand satethattheaWee information
iscormct. I agree tocomply with all city and county ordinances and sate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating tobudding construction, and hereby authorlu repmentativesof this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabNties,Judgments, cossand expenses which may in anyway accrue
Date Recei
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CIO 10,000 CFM)
SUB AL:
again said City In consequence of the granting of ties permit.
[M
AIR HANDLING IT (OVER 10,(100 CFM)
CONSTRUCTIO AX
Signature of Applicant/Contractor Date
E%IIAUST HOOD(W/DUCE
CONSTRU ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies nt or future building ore pant store or handle hazardous
Date Recei the
HEATING UNIT (TO 100,ODO RTU)
material as defined by the Cupertino Municipal Code Chapter 9.12, and the
lie.11h and Safety Code Section 25532W?
O Ye. 1$ No
Will the applicant or future building occupant use equipment or devices
HEATING UNIT (OVER IW M BTU)
TOTAL:
VENTILATION PAN(SINCLE RESID)
ISSU'Rf�MCiH'9ATE
which rout hauous air contaminants as defined by the Bay Area Air
N
Quality ManagementN t 7
1�
4havc read the bazar materials requirements under Chapter 6.95 of
�'1�Id
1
SUN N 1990
BOILER -COMP PHP OR 100,000 BTU)
SOLER-COMP(OVFR 100,000 BTU)
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
understand that it the building does not currently have a tenant, that it my
requirements
nspoibit tify the occupant ofthe regWrce
Pa
p Iss nc Certiflote otOmncy.
t
^I�'I �1 Cape lnu
NEWRESIDEMIALMECH. SQ.FT
ISSUED Y:
Owuer orautharlud agent Date
TOTAL:
L/
OFFICE COPY