20914 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 20914
////0/ - Al tom'C-,r!/
one: Q l
w /vis us EK o?S!St-6j 73 CITY OF CUPERTINO-BUILDING DIVISION 1
c°^ "a^e: Qnn LLk.N°: APPLICATION / PERMIT L _ D
9 KHJ �d' a'��Tia • BUfLDING-ELECTRICAi pLUMBiNGMMI IANICAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRFCPERMIT FEE BUILDING PERMITIINFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENS I:a CONTRACTOR'S DECLARATION
]hereby
.(fines that] ivsi=3ofhem licaresed Business
Chapter
ssions9(mmmme- APPLIANCES DENITA B RIPTI `�
Ingwith
tel'i.Section 7- anDIVIslon3oftheBusinnsandProfnslonaCnde,and my
Line s b info (o and ic.# PANELS L /
License Ves LICMo2 Ry Le-a-e-d-
DateContractor (/
ARCHITECT'S DECLARATION 201-1000 AMPS
❑�++00O ]understand my plansshallbeusedaspubberecords. OVER 100 PS SQ.
FT.FLOOR AREA S/SQ.R.
k Licensed Professional RCNSEL
OWNER-BUILDER DECLARATION TALC T/M
Iherebyaffirn that am exempt from the Contractor's License Law forth.
O following reason.(Semon 7¢31.5,Business and Prof..Ions Code:Any city or M O P NST.
F<� countywhich requlma permittocorotruct,after,improve,demallsh,orrepalr
K anystmenrre prlorto its eassarece,alsorequirestheappliar forsurh permiuo PO
K Ole a signed statement that he V licensed pursuant to the provisions of the
�3 ! C°ntranoraLicemeLaw(Chapter9(commencing with Section 70W),a..vi- SV Rd NGROOLEII CTRIC
ti�Os slon3ofthe Business and Profemioro Code)orthat he b exempitherefo ed VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES
<X
applicant for a permit subjecathe applicant to a civil penalty ofnet mom than
five hundreddollars nerofthepro NEWRESIDENTIAL L SQFT. STORIES TYPECONSIRUCTION
�n M.
❑I,as owner l the property,or my employee with wages r their door
rompensallon,wllldotheusork and lhestructure V nm Intended or°((.cosi for
Cl sale(Src.7044,Business and Professioes Code:The Contractors Licetue law
rlS$ does net apply to an owner of property,who builds or Improves thereon,and OCC—.GROUP RIS.UNITS
C. who d°cssuch work himself or through hisown employees,provided that such
Improvements are not intended or offered for We.If,however,the building or TOTAL:
Improvement is sold within oneyearofeampletion,the owner-builder will have
tl({kurden of pmving that he did not build or Imp..for purpose of sale.). Q'T'Y, PLUMBING PERMIT FEE FIpODZONE APN
Lf I,as..at of the pmpert),am exclusively c...... ...with limned
.trade.to comeruct the project(Sec.7044.Business and Pmfesalmia Code: PERMIT ISSUANCE / oO
The Contractors Llmnse law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) 1
Wilda or Improves thereon, and who cantracta for such pt, ects ojwith a
pjfaemet.)Banned pursuant to the Contractor's License Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
cg
�j 1 am exempt under See. B k P C for this mason
DRAINSFLOOR ROOF,ARG,COND. SANITARY Y Nr
Owner Date RECEIPT p
WOR KMAN COMPENSATION DECLARATION PER TRAP SC1300L TA% Y N
❑i hereby af(IrcertificatepIX�gps that 1 have a certificate of consent to self-Insure,ora RECEIPT N
3801Ballo/Worken'Compevauonlrourance ora certified copythercof(Sec. GAS EA.SYSTEM.1 INC4 OUTLETS PARKFEE Y N
r1
Policy
lab C.) .
/ Pollry M GAS EA.SYSTCM-OVER 4(FA) RECEIPT x
Com any B UILDING DI VIS ION FE ES
�Cerlified copy le hercbyth the city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ed
❑Certified ropy Is filed with the city Irupe[Ion division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASEIRAP PAID
COMPENSATION INSURANCE
(I'hlseectlon need not be completed If the SURA V for one hundred dollars SEWF.RSANITARV STORM EA 200FT. Date Remi til
($100)orlrmd WATER HEATER W/VENT./E.I:CTR ENERGYFEE Y N
I certRythat N the performance of the work forwhlch this permit is issued, a 0 O —
I shall not employ any person In any manner ro as[p�B� bject to the WATER SYSfF.l4/TRG77NC
Workers' peo Gwe o/Ca ma. ate O/� PAID
O Z- Applican PP as //' yy READGNITAL PLMB. :nF1'. Date Revel tic
Z O NOTICE APPLICANT:If,after making thl ertifiam of Exemption,you
should become subject to the Workers'Compemation provisions of the Labor TOTAL:
� y Cade,you=at fort hwith comply with such provisions or this permit shall be %� UI DI ••E
`> deemed revoked.
W E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there b a contruction lending agency for the perform ELECTRIC FEE
TA
an ce°fth..rkf.rwhichthbpermltt.l.s d&S .3097,Civ.C.I r
V O Iender'e Name TOL: .J]
PLUMBING FEE d
Iy L.ndee.Addreda QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I mOlfythat l haveread this application and statethat the above Information
O W -
iscormet.l agree to comply with all city and county ordleanmand Mate laws PERMIT ISSUANCE FEES PAID:
>. (L relztingto Wilding construction,and herebyauthorize repreaentativesafthb
N Z city to enter upon the abovamentloned property for inspection purposes. ALTERORADDTOMECH. Date RCCCI ill
V — (We)agree to save,Indemnify an d keep harmless the City of Cu pert lex,
against liabilities,ja dgments,costs and expenses which may In any way a¢rue AIR HA NDENG UNIT(TO 10,000 CFM) SUBTOTAL:
against old City In consequence of the gra ring of this permit.
AIR HANDLING UNIT(OVER I Q000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date FXIIAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:.
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant.1future building occupant store or handle hazardous HEATING UNIT OO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 91Z and the _ Date RCCCI ted
Health and Safety Cod�loo 25532(a)2 HEATING UNIT(OVER IDg000 BTU) TOTAL: r #0
❑Yes No qq
Wllltheapplicant or Lure Wildingoccupantuseequlpment ordevice, VFNITLATION FAN(SINGLE RESID) IVU/*Isf(-R:.DA'L'E
which emit harardous air contaminants as defined by the Bay Area Air - li a-aips
Quality Management DlstA T BOILFR-COMPOIB'OR100,000BTU)
[]Yea L�J}N�0 , �9
]have ma dthehazardou•materialsmquimm nhunderChapter6.95of BOILFRCOMP(OVER 100,gH BTU) r �rj fv 1 ��7790
the California Health It SafctyCode,Stolons 2550.5,25533 and 25534. I t
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which mu at be mM City Of QIInPF}Iq(1
Io issuance of a Ce Cate of Occupancy.
Ownc ra h agentIV
Data L
TOTAL: ISSl1EDB L
OFFICE COPY