20888 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address: s _ 20888 31 Sire l ., G O(� (� (�
l8 l8 j8
s antsee: APPLICATION SUBMI 11 AL D777—
ser C CITY OF CUPERTINO-BUILDING DIVISION (7- t L4�D
ContractorsNNaame: {� Lie.No: APPLICATION/ PERMIT L7��
BUILDING-ELECTRICAUPLUMBINC-MECHANICAL CATEGORY CONTROLf
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h lect/En err.. Lk.No:
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� 1 Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcea PERMITISSUANCE �jj ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION 7 J
I hereby affirm that l ant licensed under providons of Chapter 9(mourrome, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwithSMion700D)of DiW9=3ofthe Budnessand ProfeadonsCods,and my
icense to lnm rec and dict. PANELS I ")�I 'WQ W�I
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Lken C » Lk.x ,6� W
Date �CHITECr .y�.�
ARCHITECTS DECLARA ON 201-I0W AMPS
O CZOC Iundeatand mypizss.h.Ubeueedupubecrecords OVERIODOAMP$ SQ.FT.FLOOR AREA $/:Q.FT.
ou U Licensed Professional SIGNS ELECTRICAL
In L7 ATION
Qnt - OWNER-BUILDER DECLARSPECIAL CIRCUIT/MISC
7p, a owing nafnrmthat ction7 xempt(roossa Contractor.License Uw fort he
o q
following reason.(Setlon 7m15,Business and Prolemlons Code:Any city or
rutq,) county which requinda permit tomtutruct,alter,Improve,demolish,orrepair TEMP.ML•TIR ORPOLE INSf.
m� '1 nystm=mpdortoibL ance,al mqulreetheappllmntforsuchpermitto
cE file a signed statement that he k licensed pursuant to the provisions of the POWER DEVICES
m
Ou, Contractor's License Law(Chapter 9(commencingwith SectiooMOO)ofDivi.
i„'30S don3 ofthe Bustnnes and Professloracode)orthat he is exempt therelromand SWP4MING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7MI5 by any ^T
OSA app0antfora permit subjects the applicant to a civil penalty of not more than
�c five hundred dollars(¢500). t.-
'9..'¢ ❑1,aowner of the properly,or my employees with wages as their an le E9DIN7IAL. _ TR--z—�' STORIES TYPE CONSTRUCTION
C compensation,will do the work,and the.bucus,E not Intended or offered for
$ D sale(Sec 7044,Boston,.and Profeadmis Code:The Contractors License Law
fig$ does not apply to an owner of property who builds orImproves therron,and DATE occ.cxom REsuNTs
who doessuchwork himself orthrough Nsownemployen,,provided thatsuch
improvements are not Intended oroffered for sale.IS however,thebullding or
improvementissold withinoneyearofcomplMlon,theowner-buliderwill have
t119„�arden of proving that he did not build or Improve for purpose ofsele.). QTY, PLUMBING PERMIT FEEty, LIppD ZONE APN
LJ 4 as owner of the properam exclusively contracting with licensed PE2ZMI7ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions,Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT WATER(EA)
Wilds or Improves thereon,and who contracts for such p4ojects - •
with a -
conactor(s)licensed pursuant to the ContraRor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• Date
WORK MAN COMPENSATION DECLARATION RECEIPT x
PER TRAP S IDOL TAX Y N
E31 hereby affirm that I have•mmncate of consent to self
ora p
cerciflcaWorkere'Compeatlon lruurana ora certified copyChemo RFCEI rr
38M, FIXTURES themof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polis labb C.) re
Cnn GAS EA.SYSTEM-0VER 4(EA) DING DT p
Y BUILDING DIVISION FEES
CcAlfled copy I.herebyfurnished.the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy V filed with the city Inspection division.
CERTIFICATE OF UEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE `�•4
(Thissection need not becomplted lithe permit dollarsSEWER-SANITARY-STORM EA.2001forms,hundred dolla '7. Date RCcei t#
($1 W)orleh WATER HEATFRW/VENT/¢FLTR ENERGYFEE Y N
Icerillythat in the performance o(the work forwhlch this permit la issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSITN./TREATING
Worker.'Compensation Laws of California.Date PAID
-
zZ Applicant NEWRP9DENTIALPLMB. SQ.Rf. Date Rece1 t#
Z O NOTICE TO APPLICANT.H,after making this Certificate of Exemption,you
should become subject to the Workers'Cr mpensatl0n pmvulom of the Labor TOTAL:
fA Code,you=at forthwith comply with such provisions orthis permit shall be Q
W j deemed revoked. BUNG FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d ThembyafOmn that there b,a construction lending agency for the perform ELECTRIC FEE
D Z ance of the work(ar which this permit B issued 3097,Civ.Q TOTAL:
U O Lenders Na re PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I coolly thatl have readthis application and datethattheabove ln(ormaHon
ucomd.I a gree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID,
>. U) relating to Wilding construction,and herebyauthoriae representativesofthls
Zcity to enter upon the above-mentioned pmperty for Inspection purposes. ALTERORADDICIMECH. Date ReCCI t#
— (We)agree to save,Indemnify an d keep bareness the City of Cu pertlno P
against liabilities,ja dgments,cods and expenses wh lch may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against ea City lnroneequence,fth,grantingof this Its it.
A, 1 `� LtD
mAIR HANDLING UNIT(OVER lD,000 cFM) CONSTRUCTION TAX
si mreo ppicaint//Contractor _I /a�''�i to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle haaardom HFATING UNIT(TO IW,WO BTU) ' Date ReCCi t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Heahhand SafdyC ion25532(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
17Yes 0
Will the applicanto metre building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) R.jSytNCE DATE
which emit haaardous air contaminanlsas defined by the Bay Area Air K` �`
Quality Management Dlaid BOILER-COMPDHPOR 100,0W BTU)
Yo Cp
have read the hazy ous materials requlremenhunder Chapmrb.95o! BOILER-COMP(OVER100,000 BM SE
the Gllfomla Healthk fety Gode,Sectsons255HS,25S33 and 25574.1
understand that lithe building does not currently have a tenant,thatit is my NEWRESIDENTIAL MECH_SQ.Fr.
responsibility to notify the occupant of the requirements which must be met (s{}tr a r�peria
prjwtplssuanreofaCcdlf,ateof Occupancy.OwnerowrauYL�L RAS
thoriud gent Datd�� ISSUED BY:��X71/���Qi xa,/{iwv'w5
TOTAL:
OFFICE COPY