20626 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Pm ed IdendfIcatlon I ^ PERM TNO.
Building Address: 20626
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10+9q IZAM PA-Izrr
mer „ one:
w arao e 1" f 21S'L— �. G CITY OF CUPERTINO-BUILDING DIVISION 13-0/
A —g D
!• Contraddr'aNan ryF�fj Lie.No: APPLICATION I PERMIT 7— J -/
""`ter' BUILDINGELECTRICALMUMBINGMEC}I LAICAL CATEGORY CONTROLX
Archimet/Engineer. Lb.No:
QTY ELECTRICPERMIT FEE ' BUILDING PERMIT INFO
Address: PERABTISSUANCE `� ❑ 1:1 El
CONTRACTOR'S DECLARATION �{
I herebyafilrm that l am licensed under pnevblons of Chapter 9(commenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
with Section 7000)of Division 3 ofthe Business and Professions Code,and my
license is inf I�LY P-y'yIs rANPANELS ../ T. /4
License .I
Cl.. -Jap
ss ont J `7✓ �-�I/'TNT `PTI
Date Contractor
ARCHITECTSD LANA 16 - I-1000AMPS
qq��++ON Zp -I understand my plan shall he used as public records. OVER1000 SQ.Fr.FLOOR AREA $/SQ.Fr.
Fa u Licensed Professional - SIGNS ELRC
6 OWNER-BUILDER DECLARATION sPECA IRC LSC
p, 7 I herebyaffiren that lam exempt from the Contractor's License law for the
Zo fallowing reason.(Section 7m15,Business ad Professions Code:Any city or
FZ cl muntywhichmquimapermlttomtutmdalter,impmve,dem it h,orrepalr TEMP.M LE
anystm=mpdortolte mance,abomqulreatheappliwntforsuchpermitm
PJ r�G file a signed statement that he Is licensed pursuant to the provisions of the POWFR D -
3w Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi.
O� sion3 ofthe Buslnessand ProfessionsCde)orthe hell exempt therefromand MIN LEL C VALUATION
y.'S the basis for the alleged exemption. Any violation of Section 7101.5 by any
e appticantfora permit subjectstheapplicantd mreTC
tua civil penalty of see O HFSIT FS 17-16 (7
five hundred doll..($500IL NEW AL t Q
�n ❑I,as owner of the property,or my employees with wages as their sole STO TYPE CONSTRUCTION
I. compensation,w111do the work and thestructure is net Intended or offered for
Osale(Sec.7014,Buelnesand Profemloru Code:The Contractors Llrerue Law
fd$$ does not apply to an owner of property who builds or Improves thereoM and OCC.CROUP RHS.UNITS
who doessuch work himself or through his own employees,provided that such
NK—
Improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
improvement build within oneyearof completion,the owner-W Bderwill have
tlLkurden of proving that he did not build or Unprove for purpose of orb.). QTY, PLUMBING PERMIT FEEp1AODTDNE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to roratruct the project(Sec.7044,Business and Profsessimu Code:
The Contractor's License Law dans not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ajects with a ALTER-DRAIN A,VENT-WATER(EA)
ogtSfacourts)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE_ ' FEE SUMMARY
IJ I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT M
WORK MAN COMPENSATION DECLARATION �.U��.�P SCHOOL TAX Y N
❑I hereby affirm that 1 have o lmuate of consent d selfdnsum,ora RECEIPT It
3800,mdiflLet,of Workers Comperssatlon Wuranceora certified ropythemof(Sec. GAS EA.SYSTEM-11NCAOUILEI5 PARK FEE Y N
3500,Lab C.I
Policy p RECECAS FA.SYSTEM-OVER 4(FA) DING Df N
Cam any BUILDING DIVISION FEES
Certified copy is herebyth the citcd.y
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copybfllbd with let city Wpenlon division.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE7RAP PAID
otlonemCOMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700F1' Date Remi t#
(Thissection need na be opletedpermit bforone re
hundd dollars
($I00)mIcas') WATER HEATER W/VENT/Q.GCTR ENERGY FEE Y N
I cortlfythat In the performance ofthe work forwhich this permit is issued, —
I shall not employ any person In any manner ro as to be..sub)ect to the WATER SYSTEM/TREATING
Workers Campeneatlon laws mf Gll(ornla.Date PAID
C• Z Applicant NEW RESIDENTIAL PLMIL SQhT. Date Reeei t#
ZO NOTICETOMI'Ljcd tote mkher m,'CmnpsnCertnlpro of Gs ofthe ,you
should ode,you
a eubjM ith co Workers'such p rovuhset n provisions permit
s all be TOTAL:
LU N deemed
must(orthwlth comply with each provisloe orthb permit shall be
� deemed revakd. � TNG E . / t
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE s
Il I hereby afflrmthat there is a construction kndingagenry for the perform ELECTRIC FEE
7 Z in ofthe workforwhichthb permit is bxid(Sm.3097,CIv.C.)' TOTAL:
U O lZer'sName
PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iartlfy that l have read thisappllcatlon and state thattheaboveln..don
1 beamed.IagreatOCmmplywithaEdtyandcountyodtanmsandstatelaws PERMITISSUANCE FEES PAID:
>. relatingtobullding construction,and hereleyauthmim,spereentatives ofthis
[- Z city m
to enter upon the above� entioned proInspection for pection purposes. ALTERORADDTOMECH.
V - (Wo)agree to save,Indemnify an d keep harmless the City of Cupertino - Date Reeei t#
against liabdidea,judgments,cwband expense which may In anyway accrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against said City In mnseque of the granting of this permit.
A (� t7-113--016 AIR HANDLING UNIT(OVER 10,"CTT) CONSTRUCTION TAX
Signature of Appllant/Conlmcmr Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcant or future building occupant store or hand to havirdous HEATING UNIT(TO 100,000 BTU)
reaterle l as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the _ Date Receipt# _
Ilealth and Safely Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑Yes No
Will the applicant future building occupant use equipment or devices VENTILATION FAN(SINCLE RESID) ISSU=�F,9& IT
which emit luvardom ab contaminants as defined by the Bay Area Air
��jpp
:10Quality Management D's et7 BOILER-COMP(3HPOR 100,000 BTU)
4Yes �Qyys�C}No
havemad the haz4rdausmater)alsrequirements uoderC1npt.r6.95.f BOILER-COMP(OVFR100,000 BTU) YIy
the CaliforniaHealth k Safety Code,Sections 75505,25573 and 25534. I 0 pts
understand that lithe building does not arrontly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FL
responsibility to not lfy then pant ofthc mqulremenis which mu at be met a-- OL nIIBP��Bn
prior to ua ofa Grtif to ofOmpancy CI 11
7—J3--4e d
Ownerorauthorived agent' Date
TOTAL: ISSUED BY:_ TI G4.
OFFICE COPY