20699 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
1, Building Project IdentificationPEO TNO.
Building Address:� , 511�& 1 Ln - 20699
A
CITY OF CUPERTINO-BUILDING DIVISION
�Lie.N°: APPLICATION I PERMIT
7L BUILDINC—MBCiRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Amhitect/Engineer. tjLk.N.
QlY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.,: / PERMITISSUANCE Za Od ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1"by affirm that l am licensed under provisions of Chapter9(comenen APPLIANCESRESIDENTIAL JOB DPSCRE'TION
Ingwllh Sectton7000)o(Drvaom3o(the/Businessand/P�ro(esslonsCode,and my
Iirenee lain(uLLfoue andcffxc� 9'�(o PANELS
se Lc,N fp
LicenCl�s+,Ci 4o
DateN/! Can or _ UP TO 200AMPS
TTS ARCHITECTSTHE LARATIO OVER
000 PSAMPS SQ.Ff.FLOOR AREA S/SQ,FT.
aO ZpO I understand my platy shall be used as public remade. i
lea d U Licensed Professional SIGNSELECTRIGL
G< OWNER-BUILDER DECLARATION
E"n]3 SPECMLCIRCUIT/MISC
-9—
owingraf@mthatlam exempt(romthed Professions
Licenre law fort he
following l5ectlon 70715,Basins®and Pm(esslora Code:Any city or
O TEMP.MEIEiOR I'OL Sf.
�� roantywhim requlresa pertNt to rotatmct,alteq improve,dcrtnlnh,orrcpalr
any structure prior to its Issuance,also requires the applicant forsuch permit to POWER DEVICES
r file a signed statement that he n licensed parmem to the provlslora of the
30,E Contractor'sLicense Law(Chapter9(commencing with Section 7000)of Dist- SN/IDIMINC POOL
SOS slon3.fthc Budne,sand Professlo®Code)orthathelsexempttherefmmand VALUATION
yyy the bash for the alleged exemption, Any violation of Section 70715 by any
applicant for.pnrmtaubjecatheappllcanttoadvil pewity ofnt more than OUTLETSSWI ES
five hundred dollars(5500),
NE RESIDENTIAL L .FT. STORIES TYfaECONSIRUCTION
�n ❑e as owner of the property,or my employees with wages as thele sole
comperwt0hm,K will BusBotheworkandthestmde: is not Intended oroffered for
O ssie(Sec.7044,Bwlnna and Professlom Cade:The Contnr3ora License Law
does not apply to an owner of property who builds or improves therein,and OCC.GROUP RES.UNITS
whodoesw6work himselforthrough hisawnemployees,provided thatsuch -
improvemenle am not intended oroffered forsate.If,however,lhebullding or TOT /IN
improvement lssold withinoneyearo(complelWgtheowner-bu0derwlll have
th,0„Ixrrden of proving that he did not build or improve for purpose of sale.). QrY. I P $ RMI A FEE HOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to conatrad the project(Sec.704,1,Business and Prafeubv Code: PERMIT L55 CE
The Contractor's License Law doe,not apply to an owner of property who AL IN&VENT-WA
CE )
Wilds or Improves thereoM'and who contacts for such poojects with a
A OUTSI DE FEES
cgfdratorts)licensed Pursuant to the Contractor'sLicense Law. BACK FLOW PROTECT.DE FEE SUMMARY
LJ I am exempt under Sec. B&P C for thio reason
DRAINS PLC ROOP,ARCA, ND. SANITARY Y N
Owner Datc - RECEIPT
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP -SCHOOL 7A% Y N
N
❑pr hereby ef(Irm that I have•certificate of consent to eel(-insure,w a RECEp'f N
atalificate of Worken'Cwnpevation Insurance ora certified copythereof(Sec. GAS EA.SYSTEM-11NCAOUTLETS PARKFEE Y N
3800,lab C.) '
Pa11ryN D2-Wdp-2)93,/ RECEBT CAEA.SYEM-OVE (E
R4A)
Com any CAS- ST
BUILDING DI VISION FE I7S
Certified co hh reby rn ed. CREASE/INDUSfRL WASTE I EPTOR PLANCHECK FEE
er lfled copy 6 filed with the city Inspection division, .
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STD PA.l00FT. DBIC Remi Ile
(lhbaMlOn need not be complied i(the permit n fw one hundred dollars
R100)orless.) WATER HEATER W ENT/ELECTR ' ENERCYFEE Y N
I mnot emplhat oy
any personhe In any
crooner
AS to b cam ermlt n no the
I shall not employ any person In any manner m u to become subject to the
Worlicre'Compensallon Gws of GWATER SY
ilfomla.Date TREATING PAID
O Z NOTApplICant NEW RFSI ALPLMB._SQFr. Date Recei t#
Z O NODCETO MPLICANM tothe aoer rsns'Compensation
pro la Exemption,you
thde,yoould becomesubjectforthwith
co Workers•Comperaatlonpmvnim Ferran Labbe TOTAL:
N devoted
you muet forthwllh cwnply with ouch provl+lora or this permit,hall be DIN
W > deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
C efthcIhembyffirm.rkfowhicthat renecoratmctionssu le(Sec. ag—cy397,C(,C.) perform, TOTAL: ELECTRIC FEE
M Z once of the work!car which thn permit Is issued(Sec.3097,CIv,CJ
() O Lander'.Name - PLUMBING FEE
LL H Leadses Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certl/ythatl have readthhapplicatlonandstatethattheats, information
fl is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE j2.40 FEES PAID:
} mlatingtobullding constructor,and herebyauthortze representatives ofthh
Zcity to enter upon the aWve-mentloned property for Inspection purposes. ALTER OR ADD TO MECH. Date Recei tri
— (We)agree to save,Indemnify an d keep harmless the City of Cu pert Ino P
against liabilities,judgments,mets and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againnaai Cir In onsequenm of the granting of this It
AIR HANDLING UNIT(OVER lo,"CFM) CONSTRUCIIONTAX
Sigwturcof Applicent/Contractor 'Dakar EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) , .Date Recei tM
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yee No
Will the applicant or uturebulldingocmpantvee equipment ordevlces VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which croft lav rdou,air is mlrants as defined by the Bay Area Air
Quality Management District? BORER-COMP OHPOR 100,000 RTU) d)
Yes he ❑No 6
haveread ealth&rdous Code,brcuWremenhunderC 5533 and 25er 5U,
.95 of BOILER-COMP BN) JR,
the Coliforms Health&Safety Code,Sodium25505,25533have.
am,that I O'�,�
uspornindtbatn notihe fy
the occupanting does of notcurrentlywhich
that it mets my NEW RESIDENTIAL MECH. SQFf
phortoiIss ante oa Cortiocate,of ofthercqulrementewhich must be met r 1890
ptlor to Issuance o(a Certiliatcofumpanry. - u xx�U
Owner or authorized agent Date11}y T. Y.n �ya V
TOTAL: ,N e55tJLU
OFFICE COPY