20523 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
20523
reCaFew
l� ,�Z� CITY OF CUPERTINO�BUILDING DIVISION
Contractor'sName; Lie.No: APPLICATION 1 PERMIT
r htect/ neer. BUILDING-D.ECTRICAUPLUMBINC-MFGHANICAL CATEGORY
LkCOM'AJ1Lj(�p+Z
.No: GC.Y'G J
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. 55,44 PF11M1A7ISS[JANCE
LICENSED CONTRACTOR'S DECARATION 1] 1:1 ❑O�
'I❑
1 harebyriffirmthatl Bernsetmdarr pofClapturg comc- MPLIANCESRE9DENTIAL
InhSecbonrDivision 3ofthe Bustnessand ProtessionsCode,and my JOB DESCRDTON
Ilwarse1.in full forceand effect.
PANELS
License Ckss p
Co
Date __Contractor
ARCHITECI•S DECLARATION 201-IOODAMPS
q�n ceO Zp (understand my plamsshaBbeusedu publlcrecorda OVER 1000 AMPS SQ.Fr.FLOOR AREA 5/SQ.FT.
j Licensed Professional SIGNS ELECTRICAL ` D1 `4-7O,—
OWNER-BUILDER DECLARATION SPECIAL CULT/MISC
zL, Iherebyaffirce that am exempt fmm the Contractor's License Law far the
qq following reason.(Section 70)15,Business and Profession,Cade:Any city or
G q county which required a permit toccrutmn,alter,improve,dernalkh,creepalr TRAP.M4 OR POLE IN
SI
anydtrucwrc price to Its hadance,alsorequlrcslhe applicantfm such permit to TOWER DEV( S
file a signed testament that he is Licensed pursuant to the provisions of the
3m�
Contractor's License Law(Chapter9(mmmencing with Section 7000)of Divi- ' NG PA ELE C VALUATION
SOS ston3o(the Business and ProfesekvCode)arthat hektsemptthere(romand
the bask for the alleged exemption. Any violation of Section 70315 by any OUIL I{FRET �O d �a
mem,applicant fora permit subjectsthe applicant to a civil penalty of not nnthan
4M:
five hundred doll..(y500). I
�^�n u I,as owner of the property,or my employees with wages as their sole NEW R AL Ff' STORMS TYPECONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for
90 ' sok(Sec.7044,Business and Profealom Code:The Commodes Liremo Taw t
r3$ does not apply to an owner of property who Wilde or Improve,thereon,andNIS VA
who doessuchworkhlmtdOCC.CROUP RFS.UNITSfearthrough hlsownemployces,provided that such /
Improvements are not intended proffered forsale.If,however,thebuilding or OTAL:
ImpmvementktoldwlthlnomrarefcompletloNtheowner-buUderwlllhave y
tlR,tIurden of proving that he did nM build or Improve for purpose ofukJ. Cry. PL(7A6 INGk, IT FEE
LJ L as owner of the property,am exclusively contracting with licensed FLOOD ZINE APN
'—/ mntactore to construct the project(Sm 7044,Business and Professions Code: P IT ISS NCR
The Contractor's License Law dues not apply to an owner of property who ALTER-EMI k VENT-WATER
Wilda or Improves thereon, and who contracts for such p1e)ect,with aFEE SUMMARY
�gn{Iaci licensed pursuant to the Contmemes License Law. BACK PLO PROTECT.DEVICE
am exempt under Sec. B k P C for this reason
OUTSIDE[ICES
'-
ODRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT 0
WORKMAN COMPENSATION DECLARATION
E31flpIXq,PER TRAP SCHOOL TAX Y N
I hereby d .that I have a certificate of consent Endure,
nt to self. or a
v matflat-of Workers'Comper tlonlr mnceceacedifiedcopythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE YECEB'Ts
3800,lab C.)
Pullcy p — RECEIPT M
GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FRES
Com
ropy k hercbyfuMe city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy k(Tied with the city inspection dlvblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE'IRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F1'. Date Recei t#
(TNseectbn need notbcompleted lithe permit kfororo hundred dollars MI
(5100)a
[certifyifythat In the performance o(the work forwhlch this permit is Issued, HEATER W/VENT/ELECTR ENERGY FEE Yed, N '
I shall not employ any person In any manner so a to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. A
z Z Applicant NEWRESIDENTIALPLMB. SQ11T. Date Retei t#
Z NOTICETOAPPLICANT:If,after makingthk Certificate o(Exemptlon,you
a mldWmtre bjOtoihe Workm'Compematlonpmvklmsofthe You
TOTAL:
04 Code,you swat forthwith complywithsuch provkiomorthk permit shall b,
LU > deemed revoked. •'E 3/Lr+617
aCONSTRUCTION(LENDING AGENCY SEISMIC FEE 9 . 00
Iherebyaffirm thatthemis mnstroctbn lending agency for the perform- ELECTRIC FEE
D Z anm of the workfor which thkperdut is Issued(Sec.3097,Cle.CT TOTAL:
0 O T<nder't Name PLUMBING FEE
IL Lender'.Addres, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertltythat]have read this applicatlonand stamthat theabove Information
a incorrect.l agree to comply with all city and countyiedinance,andstatelaovs PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorlx representatives ofthk
F Z city to enterupon the abovcmentbrud erty pmpfor inspection purposes. ALTERORADDTOMFCH. Date Rotel t#
V _ (We)agree to save,ImicmNfy an d keep harmless the City of Cupertino
.gabs liabilities,judgments,"sand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agoi dCity i cote of the Eng of this permit AIR HANDLING UNIT(OVER 10,030CFM) CONSTRUCTIONTAX
/ sgnamreof pp1 ant/Cortracmr I Date IX}IAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS OISCLO RE —
WilltheappllantorfutumbulldIngoccupant store orhandle haurdous HEATING UNIT(TO I00,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Ilea lth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yn No
Willthe appliantor wmbulldingoempantumequiprcntordevices VENTILATION FAN(SINGLE RESID) ISSUAp]['UpAT'F
which emit hanirdous air contamlrunts as defined by the Bay Area Air �T/A�Ri`!/�
Quality Management District? EOILRR-COMP Dim OR 100,000 BTU)
4Yea (.No
havor ad t..Ith&r�i fdy C.eriakrequlremenbunder Chapter 6.95 of BOILER-COMP(OVIR 100,OW BN) II'1 UQ 199U
the Glifornk Health h Safety Code,Sections 25505,75537 antl 25516. 1 W tP M �T
undersand that lfthebullding doe,not mvrrcntly have alenane,that It la my NEWRESIDENTIALMF.CH. SQ.IT.
responsibility to ratify the occupant of the requircnnnts which must be reel �j��f SUP AO
I
prior to issuance of a Certificate of Occo pa racy. Y Y
Owner or authorlacd a gent Data
TOTAL: ISSUEDBY�'/I_ �V U•
OFFICE COPY