20721 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdeNlficatlan I PERMIT NO.
Building Address: 20721
- cT
. nernone: A A
w Q- CL.C,ob CITY OF CUPERTINO-BUILDING DIVISION
Coatadae.Name: ,LI ;: APPLICATION I PERMIT
• L �`�"'1 Q `� BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL#
A Iter/Englneer. Lie-Nee
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrn>ql'3 Qq.�Se, E g� a� PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I Mreby affirm that l am licensed under provisions of Chapter 9(onmmenc. APPLIANCES ENTIAL JOB DESCRIVIION
ingwlth5ced.0000of Didsion3ofthe Ruslnenand PrefeWon.Cedgand m
license IS In ful rm and died. PANELS
Lken Clan macRLk.If 1 —1
Date _I %_Contractor �_ ]—�GrT.a,tc I 'PVICC
ARCHITECTS DECLARATION Nil-IODOAMPS
pZ I understand my plans shall be used o public records. OVER IOW SQ.FI.FLOOR AREA S/SQ.FT.
zCO
(/ Licensed Prafenfonal SIGNSELECTRIC
6 OWNER-BUILDER DECLARATION SPECIAL IRC
I hereby affirmthat I am exempt from the Contractor's License Law for the
O .. followingreason.(SeMonTORS,Business and Professions Code:Anydty or TIMPM L I
�� county which requiresapertNtto coratmct,alter,lmprove,demoLLvh,aerepdr
$ any structure prior to its Issuance,also requires the appRant for such penNtto ppWERD
rxE file a signed statement that he b licensed pursuant to the provblon of the
3 cc� MW
Contractor.License lAw(Ch.Eder 9(commenctng with$edlon 7000 of Dlvl- gWpr{MING ELE C
sion3 of the Business and PmfanbraCode)orthat hebexempttherefromand VALUATION
6 5. the basis for the alleged exemption. Any violation of Schon 70315 by any OUTLETSSWITC FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
Eve hundred dollars($500.
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTRSQFT. STORIES TYPE CONSTRUCTION'
p perty,or he employees with wages r thele sok
caki5e.tion,wBl ocas.workendthertmdureboot Intended proffered for
O sale(Sec.7014,Busbieas and Prvfenioma Cade:The Cantractore Licome Law
$$ does not applywan owner of property who Wilds or improves thereon,and 12.40 OCC.GROUP RES.UMTS
whodoessuch workhimself orthrough hlsoweemployees,provided that such
improvements are not intended oroffcmd forsals.If,however,thebullding or TOTAL:
improvement.sold withinoneyearofcompldion,the ownerbulWerwlll have
tln�urdao of proving that he did not build or improve for purpose of axis.). QTY. PLUMBING PERMIT FEE
LI 1,as net of the property,am exduslvely contending with licenced FLOOD ZONE APN
..trade.to construct the project(Sec.70"Shadiness and Prafessiaos Code: PERMIT ISSUANCE
The Contractor's License Law does out apply to an owner of property who
buALTER-DRAIN kVENT-WATER(FA)
Wilds or Improves thereon, and who contracts such p(ofects with
c actor(.)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reasonQIlTqIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date REC19T R '
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cerHflism of consent to self-insureFIXTURF_S PER TRAP SCHOOL TAX Y N
,ora RFOEErf R
3BW,Lab C.) S EA
certificate ofWarkers Compensation Insurance m a cortlfled copy thereof(Sec. GAS.FA. INC40I1TLET5 PARK FEE Y N
Policy M CAS-F.A.SYSTEM-OVER 4(FA) RECEIPT'N
Com any BUILDING DIVISION FEES
Certified copy is hereby te city
Certified copy b filed withh the cidty Impaction division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPT SON FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWFR- STORM-STORM EA.200Ff. DRtB RCCCI tin
(fhb section need not M completed If the permit blur one hundred dollars
(St W)aWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Io:rtify,fy that lathe pedornancoofthe work for which this permit bbsued,
I.hall not employ any person In any manner at nbecome osis ct to the
Workera'Compensatlon w.o(GR(o_rnb. Data I WATIRSYSTEM/TREATING PAID
O Z Applicant NEW RESIDENTIAL PLMR. SQFf. Date RCtt1 IN
Z 0 NOTICE TO 'P ICA : Leits making this Certlfkate o(Exemptlon,you
should become subject to the Workers'Comparwtion proal loos of the Labor G,FEE TOTAL:
P
N Code,you mueferlhwith complywthmchprovlsloosorthbpermltshallbe
j deemed revoked.
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL lherebyafflrmthatthemisam tructlon lending agency for the perform- ELECTRIC FEE (]
Z ands of the work(or which this permit b Wued(5ee 3097,Civ.C.) TOTAL:
O O Lender's Name PLUMBING FEE
IL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certlfythatl havereadthbappllotionand Yatethatthe.1Exw.nforrtallon
recorrect.lagreeto compaction alndtyandcouhoamr,prmsand date PERMITISSUANCE FEE$f'IW D:_ ,5�
Iscorrerelating toI agree
to complyworyalcityabyauntyoerepncesan lv to laws I 7
,F Z city to enter upon the above-mentioned property for Inspection purposes. ALTTRORADDTOMECIL
(We)agree to save,indemrdty an d keep harmless the City o(Cupertbw DRtC RCCCI I#
V against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a alntsald ClIn consequa..of the granting of this permit AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
.�ff&D21c —1—N-9 CONSTRUCTION TAX PAID:
igwrc tuo(AppOant/Contractar Data EXFIADST HODD(W/DIX:'O
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture bu llding occupant store or hand Is ha,cardous HEATING UNIT(TO I W,WO BTU)
matedalaa defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Receipt# _
Health and Safety Cod fjfctlon 25532(2)? HEATING UNIT(OVER I00,000 BTU) TOTAL:
1111th
Yes No LJIaa`�1t12WaTE
Will the zpplkant tore building occupant me equipment or devices VENTILATION FAN(SINGLE RESID) ISS
which emit harardous air contadwnts as defirud by the Bay Arca Air
• Quality Management District? BOILER-COMP OHP OR I00,000 BTU)
Q Yes �FZ7 No
`('have read the b..Mus materials mquircntents underChapter 6.95 of BOILER-COMP(OVERI0D,D00 BTU) bI� r isso
the Callfornia Health h SafetyCode,Sedloas 25505,25533 and 2534.I
understandthatifthebuildingdoesnotarrrentlyhavnatenant that it b my NEW RESIDENTIAL MECH. SQ.FL a.� .
responsibility to notify the occupant of the requirements which must be met City yl Cuoel l{
ino
or to Lvuance of a Certi/lcats of Occupancy.
Ownerm.uthodaed agent Date ISSUED
TOTAL:
OFFICE COPY