20901 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification' PERMIT NO.
Building Add ,: 20901
i O ci
nere ante. neo - A A
!.cacti I, = TA,-+Fr & Q1 CY96-ave CITYOFCUPERTINO-BUILDINGDIVISION
. Coatraam'aName: Lie.No, APPLICATION / PERMIT
SOUTH Q9"1 (a LV aP-v lQ1/x/Ec ylp3 q/T BUILDING-ELECTRICA4PLUMBINGMECFIAMCAL - CA=RY CONTROL It
AmMmes/Englneer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT!
Address PERhBTISSUA NCE El . ❑ E]LICENB ED CONTRACTOR'S DECLARATION
I hereby Rb OA700lutlamlke3oftheunder
usineprovisions of Chepter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRRTION
Ingweh I.fon 7000).!lefelon3o(1he BuannessandProfesloneCode,and my
liana b In fell(orae ani effect. /' PANELS
License CWas C_](Contr_ r
Date ConOactor UP TO 2DO ANTS
2011000 AMPS
ARCHITECTSDECLARATION .
re0 70. I understand my plant shall be used as public records. OVER 1000 AMTS SQ.FT.FLOORAREA g/s(j.FC.
Fi d 0 Licensed Professional SIGNS ELECTRICAL
<<�¢ OWNER-BUILDER DECLARATION SPECIALCERCUIT/MISC
7E, v Ihereby affirmthat l amexempt from the Contractor's License Law lm the
p following mum.(Secilon 71111.5,Business and Professions Code:Any city or
Fan TEdP.METER ORPOLEI ST.
countywhlmpdototto wanceabormit uuireatheaimprove,limntfrwcdemolish,or pgr
tto ^ nt
any assigned statement
lta that
he is;aUensed pursuant
totheHor of t e POWER DEVICES
ryl y Clic a ,Tim.gatemeLa that he b licensed pursuant la hetonprovisions00o! the
Con3ofthsLiceiuelaw(Chapter9(mmmenting hatheiwith Seaton7000)
and SWp{hgNG IDOL ELECTRIC . i -�
gon3ofthe Buslneasand Pro(essbnsCade)orthat he Uexemptthercfromard ` / , jJ �` � J• �" B VALUATION
o.577 the basis for the alleged exemption. Any violation of Seaton 70315 by any
appBrant fora permit scts m
ubjethe appilcant to a civil penalty of not orethan OUTLE1SSWITCFIESEXIVR 0
$ flue 1,..o nerofthepro NEW RESIDENTTALEL� TR np_— TYPE CONSTRUCTION
j.. dollars($5CM.
❑I,as owner ll the property,or my employee with wages thele sole
7 6 rot E&e.7 "wields..and PC figaim stCode:Th.C drache'or kens ed nv
O dofor
e.e not
ply to ainowner of
who
Wild,Contractor's Liceme law
[yd $
who does
apply torniweer of lf or through
OCC.GROUP RES.UNITS
CC.. whodoemnts are not msended or.ugh hieowne.If,ho ever,thebuilided atng oruch -
improvementsarenotIntended earofe p1mioe.1I,however, ilderwdingve TOTAL: .
Improvement V cold wimhlnoneyearofcomplellorythcowner-bullderwlll Mve
tlil,tioden ofproving that he did net bulla orimprove for purpose ofsale.). QTy, PLUMBINGPERMIT FEE FLOODZONE APN
"L as owner of the property,am exclusively—!-Ung with nctlicensed PFRMLI,ISSUANCE
contors to mnskua the project(See.7016,Businessand ProfessionsCode: 19,
The Commetor's License Law does not apply to an owner of property who ALTER DRAIN&VENT WA,fF$(EN Z
builds or Improvers thereon,and who contracts for such Pillte=with a
"�➢!(�&or(.)licensed pursuant to the Contractors License Law. FEE SUMMARY
IJ I am exempt under Sec B&P C for this mason BACK FLOW PROTECT.DEVICE. 8
OUTSIDE FITS•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Dace RECEIPT#
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP Z,E'' SCHOOL T" Y N
❑i hereby orke that I ee t o 1mum to of consent d spythmre,ora ttrr RECEIPT N
380cert0,Lab ofWorkerq Compewtion Wunna aacerti(kd ropy lhenn((Sec. GAS EA.SYSTEM-1 INCAOUTLECS PARK PEE Y N
policy N CJ O U! (M1 q
policy 11t, `1 CAS EA,SYSI'Qd-0VER4(EA) DING IV
st
Com any C . BUILDING DIVISION FF.F.S
�certlned copy b hereby
Cehe .
riffled ropy b filed with the city Inspection division. GREASE/INDUSRWASTE INTERCEPTOR PLANCHECK FEE
J--� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAPPAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.moFr Date Recei tk
(Thio section need not M
COMPENSATION
If thepermit SURA V lane hundred dollar P
(SI 00) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the performance oe-wetR' raw Ichlhlipertnit is ivaued,
1 shall not employ!U�piinssTln any manner w u to become subject to the —
W.rken'C Hon Laws of California.Date WATER SYSTEM/TREATING PAID
O Z Ap NEW RESIDENTIAL PLMB. SQFf. Date Rewi tM
Z O N CE TO APPLICANT:If,after making m his Certificate of Exemption,you
cc
should become subject to the Workers'Compensation provisions of the Labor TOTAL:N Code,you t forthwith comply with such provisions or this pernit shall be
Wj -madeemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iher.by.Mmtham there is a constmctlon lendingagenry,forthe perform, ELECTRIC FEE
Z ance ofthe work for which this permit is Issued(Sec.3097,Civ.U) ' TOTAL:
U O Lmde,.Name PLUMBING FEE
LLE- Lender'.Addm QTY.j MECHANICAL PERMIT FEE MECHANICAL FEE
O W i.difylhat( versadmhh.ppButl.nandgatethattheabovelnformamion
IL ba
rorr. .I agree to comply with all ety and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
relating lobulldleg construction,and hereby authorize representatives of this
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTOMECH. Date RCCCI fN
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilitkre,Pdgrrenta,mansard expenses which may in anywayaccme AIR HANDLING UNIT(1`0 10,000 CFM) SUBTOTAL:
against said City in consequenestoghe granting of this pemd6
j 1 ,1.t�J� AIR HANDLING UNIT(OVER 10,000C17M) CONSTRUCTION TAX
Sigruturc of Applicant/Contractor Date E7(HAUS'f HOOD(N/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuhtre building occupant store or hand Is hazardous HFATING UNIT(TO 100,000 BTU) Date RCCCI tb
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I lealth and Safety C Ssdlon 25532(a)i HEATING UNIT(OVER 100,000 BTN TOTAL:
Fly.
Will the a pplicant 610.a .Bcling occupant use Nolperent or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazy rdom air mntaminanms as dalined by the Bay Arca Air 11I„„_
O Qlyd'By Mamgement ISM BORER-COMP OHP OR 100,000 BTU) !
4 Yrs q[�U
By
read the hazer matedab requircmenh under Chapter(x95.! BOILER-COMP(OVEt 100,000 BTU)
the Califomu Health&SafetyCode,Stolons 25505,25533..d 255.14.1
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 most be met
prior to issuance of a Certificate of Occupancy. ('t �Unq"tl Del ,(
Cit`! 11MP\Tl(�q
Owner or avmhorized agent Date
TOTAL: ISSUED BY:_
OFFICE COPY