20534 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identtlilc�ati�on Y /� /' /�/J Y PERMIT NO.
Building Addrepa:oo P ( .A lQ&z( 06%5 Pr v z CLI '+�ubzl�a-) 20534
n r ams/-1jr /� q �f/
1'►'n Lk `Il<j& eS�; CITY OF CUPERTINO-BUILDING DIVISION
conpp Mame: n p Z36�IAPPLICATION I PERMIT —Ci O
_
Lk.No: BURAING-E,ECTRICAI.PLUMBINCMECHAMCAL CATFLORY CONTROL#
Architect/Engineer.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.: PERMIT ISSUANCE � ❑ ❑ ❑
LICENSEDCONTRACTOR'S
under SDECLARATION
I hereby do 7000)sl lvigomedhe Bugne§sa of Chapter9(mnvn.e APPLIANCESRESIDENTUL JOB DESCRIPTION
Ihersa ifull 70(0)o(it efelon3 afthe Buelrussa P selonsCode,and my
Iimnse ts In full and d(eit PANELS �� A � M I
7.
License Lic.I ��1�../
Date ontractor (I 416n PIZ UP TO 2DO AMPS
CHITECTS DECLARATION 201-1000AMP5
��ppuv p X CI undr.t.rd my plansshall be used as public record.. OVER I ODD AMPS SQ.Fr.FLOOR AREA f/SQ.Fr.
k d� Limned Prof.1b 1 SIGNS ELECTRICAL
-4!� OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MISC
Iherebyaf rm that[amexempt from the Contractor's License Lawforthe
V� following reason.(Section 7m15,Business and Prefessns ioCode:My city or
O TEMP.MErMORPOLEINST:
KIS munrywhkh requlresa permittoconstroct,alter improvemo
,delbh,orrcpalr
any structure Prii its issuance,also mqulr.the appVcsntfor such permit to POWER DEVICES
Ole a signed statement that he b limned pursuant to the pnevblons of the
Contractor's Llceme Law(Chapter 9(mmnrnchg with Section 7000)of Divi-� VALUATION O sion 3 ofthe Business and PlonsCode)orthat he b exempt thercfrornand SWIMMINGPOOL ELECTRIC
re(ess
the basis for the alleged exemption. Any violation of Section 7031.5 by any OITILETSSWIICFIESEKTURIS 1
�.r••�
65
applicant fora permit eubjedetheapp8cant to a civil penalty d not mom than 1
five hundred dolltrs(3500), NEWRESIDENTIALELECTR
�n ❑I,as owner of the property,or my employees with wag.as their sots SQFT. STORIES TYPE CONSTRUCTION
compensation,wllldothe work,andthestroclure la not Intended or offered for
p sale(Ser-7W4,Buslmn.and Penfe sk me Code:The Contract.e.Lt..law
�$ does not apply to an owner of property who Wilds or Imprwn thereon,and OCC.GROUI' RES.UND'S
who does such work himself orthrough his own employees,provided that such
Improvements are not intended or offered for sale.IL however,the building or TOTAL:
Improvement b sold within omycarofcompiniory the ownervbullderwlll have
the burden ofperving that he did not build orimprove for purpose cleats.). QTY, PLUMBING PERMIT FEE F'IppD7ANE APN
0 I,as owner of the property,am exclusively contracting with licamed PERMIT ISSUANCE
to construct the project(Sec.7044,Business and professions Code:
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN k VENTWATER ffA)
Wilds or improves thereon, and who contracts for such pao)ed - -
a with a FEE SUMMARY
C7R(ractor(s)licensed pursuant W the Conuactol's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under See. B k P C for this reason
OUTSIDE FEES
OwnerDRAINS FLOOR ROOP,AREA,COND. SANITARY Y N
Date RM
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCIdOOL TAX Y-- NN
❑1 hereby affirm that I have a artiBmle of consem to se141nure,ora RECEPT N
3800,1 eofWorken'Compewtlonrnsuranmmacertlfled copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,[ah CJ •.s'�'75/
Policy tl 1 J C] RECEIPT#
Com any CAS EA.SYSTEM-OVER#(EA) - BUILDING DIVISION FEES
cert led-py hreby Indeyl YN CREASE/IN'DUSTRL WASTE INTERCEPTOR PLANCHECK FEE
led copy b filed with the cityInspection divlslon.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWEIb5ANTIARY-STORM EA 700FI. Date Remi t#
(This section need not be completed if the permit b(Drone hundred dollars
(8100)°rte®•) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify thatto othe person
ework for which this permit
subj I. the —
I ehe11 not employ any person In any manner at as to become abject ro the WATER SYSpEM/TREATING
Worken'Compensatlon laws of California. Date pplp
O Z Applicant
Z NOTICETO APPLICANT:If,after making this Certificate ofExc=n,yeu NEW RESIDENTIAL PLMI, SQJM Date Remi t#
Hshould became sub)ed to the Workers Compensation provisions (lhe Labor TITOTAL:
W
Code,you=at forthwith comply with such provisions orlhb permit shall be
� j deemed revoked, U t
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afftrm that there b a construction finding agency for the perform- ELECTRIC FEE
Z ance of the workfor which this permit Is Issued(Sec.3097,Civ,C.) TOTAL:
02 Lender'.Name PLUMBING FEE .
IL Ienderanddress QTY- MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mAilythxt l have read thin application and statethattheebovelnformallon
1 ismrrcd.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building mon
nstrudi ,and Wrebyauthome representatives of this
co
F Z city to enter upon the above,mentioned property for impaction purposes. ALTER OR ADD TO MECIL Date RBcei t#
V _ (We)agree to save,indemnify an d keep harmless the City of Cu pert Ino P
again thejud ta,dest cdexpe�hmayi anywy.... AIR HA NDLING UNIT(To 10,000 CFM) SUBTOTAL:
a et sal CI In a sae of the ntin ofthis It�1
w ! _ w AIR HANDUNC ITNIT(OVER 10,000 c1M) CONSTRUCTION TAX
Slgnsturee(Appllcanl/Contractor �O Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllitheappiiont or future building occupant store or handle hazardous HFATINGUNIT(TO100, BTU)
material as deflred by the Cupertino Municipal Code,chapter 93Z and the Date Recef t#
Health and Safety CoddajaIll7-533(a)) HEATING UNIT(OVER 100,000 TU) TOTAL:
I-1 Yes 191% - s
ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamimets as de0ned by the Bay Area Air
na
Quality Magcnart M%fr[O BOILCR-COMP(3HPOR 100,00f)BTU)4PAD havc read the haze our3 smalerfals requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU)
the California Health k Safety Code,Ben lone 25505,25533 and 75534.I
understarad that if the building doe.not currently have a meant,that It I.my NEW RESIDENTIAL MECH. SQ.FT. J11`�
responsibility to notify the ompm
ant of the requireents which must be met V
' ro asses ofa iiia. f0cmpim raOw BtlQ
ncrarauthod.o.gem Data
TOTAL: ISSUED BY:
OFFICE COPY