20588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ee Identification I PEILWTNO.
Building Address: B` JF— 20588
nenIt".Name AA
�(Gj a3� CITY OF CUPERTINO-BUILDING DIVISION
o tr or.Name: Lie.No: APPLICATION /PERMIT l7 l
BUILDINGFLECnUCALMUMBING-MECMNICAL CATEGORY CONTROL#
Architect/Eagincer. Lic.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrese: CPERFBTISSUANCE ❑ ❑ L ❑
LICENSED CONTRAFOR'S DECLARATION
I MhSWiolrmthatlam Ocen3 ofte Busine,andPrf Cssiona9dr,and c APPIlANCESRE51DEN1TAl JOB DFSCRB'iTON
ingwlthSW Ion71100)of Division3 ofthe Bwinneand ProfcsponaCode,end my
license is m: and dice. PANELS
Lkenx Lle.N �—
Dale /. .s� p}s[��•onlraeor
-Y— ARCHITECT DE RATION 201-10pp A.4iP$
nI I understand my plan shall be ux as public records OVERI"AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
CO
(� Licensed Professional I SIGNS ELECTRICAL
¢ OWNER-BUILDER DECLARATION SEE
Fo' ap I herebyafBrm thatlamexemptfm the Contractors Lteense awforthe
O following reason.(Section 70015,Bus ss and Professions Code:Any city or TE Mp METER OR POLE INST.
W cwntywhichrequirnapemuttoromt ct,alter,lmprove,dennlish,orrepair
q Q anystroctvre priorto lm lswancc,also quirestheapplicantforsuchpermitto POWER DEVICES
E V
file a signed statement that he b Ike sed pursuant to the provisions of the
Ow
Contractor's License Law(Chapter 9 commencing with Section 7000)o(Divi- SWIMMING IDOL ELECTRIC
30� sion3ofthe BusNessand Prefessio Code)orthahelaexempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCHESFIXTURESr1 '
pig+ pplicant for a permit subjects the applicant to a civil penalty of not more than
IL
Ca� jIv�c ndrcd dollars($SWI. NEW RFSIDF1J71AL &CTR 1I .FT.
�1II,��as owner of the property,or my employees with wages as their sole J RIES TYPE CONSTRUCTION
c�noensation,wllldothe work and thestructure ls not Intended or offered for ^�
p /ale(Sec 70K Business and Prolestiora Code The Contractors License Law
does set not apply to an owner of property who builds or improve thereon,and C.GROUP RES UNITS
c•"^ who doessuchworkhmaelforthrough hisownemployees,provided thatssch
Improvements are not intended orolfered lorsale.If,hcweveq thebuilding or It y TOT
i provemcntusoldwithinonerarofcompIMlb theowner-bu0derwillhave
tl(,,,kurden of proving that he did not build or improve for purpose ofsak.). QTY. PLUM TNG MIT FEE FLOOD ZONE APN
LJ L ae owner of the Property,am exdu.+ively contracting with Ilcenxd pp(MIT LSSUAN U1
contractors to construct the project(Sec.7614,Business and Professions,Code: j/.`
TM Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER MA)
Wilds or improve thereon,and who contracts!or such projects with a FEE SUMMARY
y(actor(s)Bcenxd pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reasonOUTS I DE FEES
DRAINS FLOOR ROOF,ARG,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER.IRAPSCHOOLTAX Y_ N_
T71 hereby affirm that I have a certifieate of consent to self-Insure,or a RECEIPT N
omIfiateof Wmka Compensation Wuranceora emifkd copy theacuf(Sec. GAS G.SYSTEM.1 INC.4OU LEIS PARK FEE Y N
3800,Lab C.) RECEIPT N
C2mPolicY GAS E.A.SYSTEM-OVER4(EA)
Com any BUILDING DIVISION FENS
'Bed
copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE
rtifad ropy Is filed with the city inspection division.
,XP
CERTIFICATE OF O(2M PON FROM WOR K ERS' GREASE TRAP
TIPAID
COMPENSATION INSURANCE SEWTR.GNHARY-STORM EA.20017. Date Recei lift
(This section need net be completed If the permit lis forom hundred dollars
(s1W)mless.) WATER HEATER W/VENT/Fd.ECTR ENERGY FEE Y_ N_
performance certify that In the perfoance of the work forwh1 h this permit la issued,
1 shall not employ any person In any manner so as to become subject to the WATER 5YSTEM/TREAUNG
W orkerd Compenwtion Iowa of Callfornu.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFI'.
i- Date Reeel t#
Z O NOUCETO APPLICANT:T{aher making thisCertificate.(Exemptlogyou
should become subject to the Workers'Compensation provulors of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthu permit shall be BUILDING cc `J deemed revoked.
W
— CONSTRUCTION LENDING AGENCY SEISMIC FEE
!1 I hereby affirmthat there lit a construction lendingagency,for the perform- ELECTRIC FEB
M Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O lander.Name PLUMBING FEE
LL ~ Lenders Address, QTY. MECHANICAL PERMIT FEE MECHANICALFEE
U I cenlfythatl have madthuapplicationand statethat theabovelnformatlon
O W Is correct.T agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
r 4 relating tobuikingconstruction,and herebyauthoAssrepresentativesof Nu
F
?z citytoenterupontheabove.mentioned pmPertyfor Ls,pWionpurposes. ALTERORADDTOMECH.
(We).gree to save demnlly an d keep ha Mess the City of Cupertino Date Receip[ft
V ago ides. n rats,mesa expenses whkh ma anyway acauc AIR HANDLING UNIT ITO I0,000CFM) SUBTOTAL:
Inst s d Clty 1 con a permit.
AIRHANDLING UNIT(OVER 10,000CF11) CONSTRUCTION TAX
III
f Ap / ontractor Date EGIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
applicant orfuture building occupant store or handle havnicus HEATING UNIT(TO 100,ODO BTU) Date Rea01 f#defined by the Cupertino Municipal Code,Chapter 9.12 and the
Safety Code SWlon25S32(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Q111W
❑Yea MN.
Will the applicant or future bit ilding occupant use equipment or devices VENTILATION FAN(SINGLE REID) ISSUAI4 EW
which credit hamidous air contarmna nts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OFR'OR 100,000 BTU) -
Q Yn �No <J Wt Q 1
I have read the hazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVE2 IW,0W BTU) I�JU
the Coliforms Health&SafetyCod,SW ions,8505,25533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. S(j.FT. S
responsibility to notify the occupant of the requirements which must be met City. of CaperFin®
priortolssu..ce a.Certificate of Occupancy. �'��
Owner or authorized agent Date ISSUED BY: 1. -Is
TOTAL: r q—
OFFICE COPY