20859 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PFRMITNO.
Ba 1117F R 6i" 01 O/L 20859
6 dnC: OGG:
�,(, � CITY OF CUPERTINO,BUILDING DIVISION Qa. /• �O
G r.n°""/'"4,G:v uG.N°, APPLICATION / PERMIT
C- JI^���`7TNS 6 BE
LDINGELECTR CAL(LUMBINGMECHAMCAL CATEGORY CONTAOLN
ArcbltW/Engineer. Lic No:
QIY ELECTRIC PERMIT FEE' BUILDING PERMIT INFO
AddM99
7'FRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby af(im,thetlam licensed under provisions of Chapter9(rommmc- APPLIANCESRFSIDENTIAL JOB DESCRIPTION
ingwlth Se&ion7OW)of Dlvision3ofthe Busineeeand ProfenlonaCWe,end my
license Is In full rce and effect. PANELS
at Contractor '
ARCHITECT'S ECLARATI201-10W AMPS
PQ+ O I understand my plans shalt be used as public records. OVER 1000 AMPS SQ.FT.FLODIR ARIA $/SQ.FT.
E obE Licensed Professional SIGNS ELDCTRICAL
ul
DI OWNER-BUILDER DECLARATION SPEC IALCiRCUIT/
ZL, a son(hereby affirm that l sexempt from the Contractor's License Law for the
O ... following reason.(Section 7MI.S,Business and Professions Code;Any city or TEMP,METER OR]'O
FSI county which requires a permit to construct,alter,Improve,demolish,or repair
�Gany structure prior to its issuance,also requires the applicant for such permit to ppSVER DEVICES
K Ole a algned statement that he is licensed pursuant to the provisions of the
Gj O Contractors License law(Chapter 9(commencing with Section 7000)of Divi- SWIN&MBPOOL ELEC
cion 3 ofthe Business and Professions Cods)orthat he b exempt therefromand VALUATION
the dials for the alleged exemption. Any violation o(SMlon 7031.5 by any
<
the
fcrapermited exe ption. Any
of Ss Joaf not morel hon OUTLETS— TGIiFS IS L�W
fiv�undred dollars(550)).
1,as owner of theproperty, NEW REST AL EL STORIES TYPE CONSTRUCTION
7< ix,a or my employees in with wages r their sole
compensation,vellidoth¢work,anaelma, odure Isnot Intended oroffered(or
O sale(Sec. pply y to alnowandf property
Code:The Wilds orimproneContractors License Law
doeanotsuchoan owner ofproughhisoeemporimprovvidedtatand
0.0. impmvewhodocntsamnkh tededolf roughhisownemploowevrthebthatauch OCC.CROUP RFS.[RJH'S
Improvementsarenotintendedoroffeco (orale.If,h ne,r.gtheerwilI have TOTAL:
Improvement isaold withinoneycar°fcomplellorytheowner-bu0derw111 have
tfo*rden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT frE FTAODTANE APN
Lj L as owner of the property,am exclusively contracting with licensed ppf.f.ISSU�CE
contractors m censuuct the pro)ed(Sec 7044,Bualnass and Professn ioCode:
IIs Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEN7-
bullds or Improves thereon,and who contracts for such pT*u with a WATER TA)
�( dor(s)licensed pursuant to the Contractors License Law. gpCIC FLOW PROTECT.DEVICE FEE SUMMARY
c L_f I am exempt under Sec B& P C for this reason
OUTS I UP FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
QI hereby affirm that 1 have a Mrtifiate of consent to self-insure,or a FD(TURES PER TRAP SCHOOL TAX Y N
artlflate of Worken'Compensatl°n Insunnaora Mrtifled ropythemof(Sec. RECEIPT N
3800,lab C.) J GAS-EA.SYSTEN-1 WC.40VILI:TS PARK FEE Y_ N
P°11cy It '6 RECEIPT
N
Com any__�r _ --- CAS EA.SY5TEM-OVER4(EA) BUILDING DIVISION VISION PRE5
�C°rtl(led copy is heed with the
ed.city GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�Ccrti(led copy is(14d with the tlty Wpcctlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlssectlonneed not becomplcled lfthepermit isforonehundred dollars SEWER"SANITARY-STORM EA.200FT. Date Receipt#
($100)orfess) WATER HEATER W/VFNT/ELWTR ENERGY FEE Y N
performance that the perfounof the work for which this permit is issuM,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawn of California. Date PAID
O Z Applicant
Z p NOTICETOAPPLICANT;If,after making thisCertificateof Exemption,you NEW RESIDENTIAL PLMB. :n.IT. Date Recei t#
N
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you=at forthwith oomplywith such provieursorthls perndtshall he
W > deemed revoked. -BUILD[N s
a Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
7 hereby affirm that there Is a construction lending agency forthe perform ELECTRIC FEE
anceo(the workforwhichthb permit is issued(Sac.3097,Cie.C.) TOTAL:
O O lender'.Name PLUMBING FEE
IL F Lender`sAddr°sa QTY. MECHANICAL PERMIT FEE MECHANICAL FBG
O W Icedifythatlhdvemadtbis application patethattbe above Information
1 bcorma.I agmeto comply with act city and countyoofloanmand state[am PERMIT ISSUANCE FEES PAID:
W relating to building mmtmctton,and hereby authorlu representatives of this
U) city to enter upon the above,mentioned Property for Inspection purpose, ALTERORADDTOMECH. Dare
V — (We) a to sq�a, a n d kap harmless the City of Cupertino Receipt#
agairstl bl tl-a,jTa(me s cad expenses which may In any wayaccrve AIR HANDLING UNIT(fO 10,000 CIM) SUBTOTAL,al i City con a the gra nun of this permit AIRHANDUNG UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
r
S' ria fApplHAZARDOUSor L D(ITADST fI00D(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE —
Wllltheappllantorfeture building occupant store or handle hazardous HEATING UMT(TO100,000BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
H71 vend SafetyCode,Seg)ion 15532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ♦ O
Yce No
Will theappbcan tum building occupant use equipmentordr ice. VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazard sair ntaminants as defined by the Bay Arca Air
' Quality Mawgement Dis ct7 BOILER-COMP pFI'pR l00,Om BTU)
Yca No P�rh
have read the ar oua rtuteriais requirements underChapler 6.95 o! BOILER-COMP(OVER IOD,000BN) - V4Ji
the California Heath&5afetyC Sections 25505,25533and75E34.1
understandthatlflheb If not.urze tlyhaveatenant,thatitlemy NEWRFSIDENIIALMECA. SQ.FT /I�s
A�Crthoriwdagc
eo a t of the requirements which a ¢met Vll 1Ano
e e Occupancy. ,OJ
I D e Y-.
TO'!AG ISSUED BY�1ll
OFFICE COPY