20558 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProjectGldentlfkel �— PERMIT NO.
,.Bd� pceudok6
20558
ens � one
APPLICAM
F vlut-t CITY OF CUPERTINO-BUILDING DIVISION A
Contra «eNamc: Lk No: 6.--� r
F� LF�F� APPLICATION / PERMIT 9
II BI1TMW—E.BCMCALML INGMECHAMCAL CATEGORY CONTROLI
ArchRed/F gf neer. Lie.No:
Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. I'FRhRTISS(JANCE ❑ ❑ nom, ❑
LICENSED CONTRACTORS DECLARATION I�jJ
Ihthb o 7DthatlamlianaedueBuM kldPmfeWmsr9(mmmmc APPI.IANCFSRFSmEMTAL ]OB DESCROMO
Iice.1 Section to.)and
efldm3Mthe Busineaeand PmlesdmsCode,and ������
I ict 1,1.full loan anddied. PANES
Date a C.orLxe.iUP1��C
Date 'b/ forITECT I11Cd1 (vim
ARCHITECTS DECLARATION MI-1000AMPS
I undentad my plan stun be used as public needs. - OVER 1000 AMPS .FT.FLOOR ARM
Lkxnsd Prof®Ionil SIGNS EIXZMJCAL J
�< OWNER-BUILDER DECLARATION SPECAAL CIRCNT/M19C
I hereby afRrtn that lam exempt from the Contractor's License Law for the
pp folbwwhichon.(Sediwi7031S,Busbea and Pmfeabru Codr.Mydty yr
OF'l.f- TEMP.ME7ER OR IYJLR INST.
EQ muntywhlA requbesapcmatto comlrud,alter,improse,demolbhorrtpalr
Y anystmd mprbrmlbbsuamc aborequb theappbontf¢suchpen w TOWER DEVICES
K+ Rle a algned that b statement t he licensed pursuant to the provbbu of the
G4 Contractor'sLlcerme Law(Chapter9(commendngwith Seaton7000)ofDM-
OS slon3oftheBuMnmsandlkafeabuCode)orthathebeumptthertfromand SWPdh9hGIVOLERCRC VALUATION
•1 - the hub for the alleged exemption. Any violate.of Sedbn 70315 by any
r� <� appllontfora permit mbjMs theapplicant to.doll penalty a..mors than OUTLE'ISSWITCHIS-FIXTURES
y live hundred dollar.(x500).
�I,as owner of the property,or my employers whh wages as their sole NEW RESIDENTIAL ELECIR SQF7. STORIES TYPECONSIRUCTION
Z4t conpouaHm,will do the.1,and lheerucrme b not tMal
eea or offered for
,Fp sale&,7014,Bualneaaand Prohnaem Code:The C.Mrad.e.Litt.Law
Ir8 doraotapplyto an—w .fpropeMywhobulldsorlmpravnthereogand OCC GROUP RES UNITS
whodoeesuchwort hlmseu¢thrwgh hisown emplgeee,prwded theoch
Improvements arc wt lntencied proffered faeale.I(however,thebuilding or TOTAL
Improvementboldwhhl omrarofcompleer6theawner-0uaderwlllhave
tIF*rdeoofpmArgthe hedfd ectbuild orlmprovef¢purposeofnb.). Qn. PLUMBING PERMIT FEE
LIT, erty
an water of the prop ,am exchuhrcty,mntrading with I4eraed FLOOD IDNE AM
contractors to conMmct the project(Sec 7014,Businev and Pmfeabm Code: PERMIT ISSUANCE
The Contractor's License,Law does not apply to an owner of property who ALIIILDRAIN4 VEM-RIOTER(EA)
brads or Improve thereon, and who contract, for such M),ca whh a
JB¢ud pureant to the Contractors License Law. BACK ROW PROTECT.DEVICE FEE SUMMARY
I am exempt order Sec B &P C for tints mason
QIlTqIDF
DRAINS FLOOR ROOF,AREA,COND. SANITARY. Y_ N
� Owner - Dee RECEIPT0
:y9y WORK MAN COMPENSATION DECLARATION FTXIVRF_S PER TRAP SCHOOL TAX Y_ N_
rt• hereby affirm the I have•mrHBute of consent to Dpyt e ¢a RECEIPT Y
¢rtRi¢te o(W orkers'CampensaHon Noonan¢¢a certllled espy therca((Sec
3800.I.b G)G)S26 GAS F.A.SYSTEM-1 INCA OUTLETS PARK FFE Y_ N_
Cam nv VJ r1ll�5Q 779 GAS pA.SYSTEM-OVER/(FA) BUILDING RECEIPT
#
ION FEES
�CertlOnd copybhereby(umbhnd. GREASE/wouSIRL WASTE M'MCEPTOR PLANCHECK FEE
+CertNd copy b(ikd with the city W pectlon dlvWm.
CERTIFICATE OF EXr PTION FROM WORKERS' GRFASETRAP PAID
-
(This
SEWV SANITARY-STORM EA Z)UT Date Recti tM
OTd T.rection serad be completed If mib rt
tort pert r«nn<nMnaa anu,rs
B100j Ot I.) WATER HEATER W/VENT/ELD= ENERGY FEE Y_ N_
I certify thet b the peeorman¢of the work kowhirh this pemdt b laced,
1 slog nm employ any person b any manner o u to become subject to the WATIR SYSTGf/"IRFATIhG
Werken'Comeb
perun Lawsof California.Date PAID
PP NEW RESIDENTIAL PLMB.�SQ.FT.
A pant
ZO amiid beccoesub),ttoETO theafterrrs'Compereathepovisicate of Exemption,you Date Repel t#
ahmldbemmemrthwit tcomply with
compereatlmp,o.wunaofthe Lobar TOTAL:
W~ N fndgyoudir muefmlhwlth comply wlthsuNprovbbv orthb pemdt shill be BUILDING
] deemed revoked.
CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Q. O
Z Ihereby affirm that there b a mrmmdlon lending agency for the perform. TOTAL
U ELECTRIC FEE
= once ofthe work forwhlch thio permN b h+uea(See 3097,CIv.C.)
O Lender.Name PLUMBING FEE
LLI— Iendee.Adare.. QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
O W Icedlfy the l have read the,.ppl"Fort.nd Mate thatthe above Informationbcorca.Iag,e Wromplywlth.H cRyad cwntyordlnan.md state laws PERMIT ISSUANCE FEES PAID:
1 N rclaHrig to building covtsuctlon,and hercbyeitherbercprtsenalhesofthb
f. city to enter upon the abavcmembnd property f¢hopectlon purpo¢a. ALM OR ADD TO MECFL
Z
_ (We)agree to save,Indemnify an it keep harion.the City of Cupertino Date Recei til ,
against habBitlee,Ndgmena,coats a d expenses whbh may in any way accrue AIR HANDUNG UNIT(TO 10,000 CFM)
ugaiat said CRy in consequence of granting a this permit. - SUBTOTAL:
AIR HANDUNG UNIT(OVER 10,000CFAn CONSTRUC1IONTAX
w Lr 7
sl6 I$ i t` D,te EXHAUSTHOOD(W/D)Cn CONSTRUCTION TAX PAID:
HAZARDdUS MATERIALS DISCLOSURE
Wllltheapplkant or futum WRding¢.pant sort or handle havrdous HEATINGUMT(TO 10D,000BTU Date Recei Ik
materbl as defined by tin Cupertw Murddpal Code,Chapter 9.1Z,+rad the
He❑alt'a rad SafetyCodea eSSectiom7553ZG)7 HEATING UNIT(OVER 100,000 BM TOTAL: Z
Will the applkira¢future build ing ompant use equ 1pment or civ VFNTI LATION FAN(SINGLE RESID) ISSUANCE DATE
r which emit havrdous air contaminant.u de0red by the Bay Area M
Quality Management Dlslrict7 BDILFIFOOMP(3HP OR 100,000 BTU)
\' Ym ❑No
4have
rcdthe hMous
rdau metrtabrequiremenbunderChapter6.95af BO ER{bNPOVER100,0006R7
the Gllfomlx Health&Safety Cole,Sections 25505,75533 and 75534. 1 JUN E 6 1990
undeutad that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MUCH. SQ.FI'
respoulbBtty,to notify the occupant of therequtrtrrent.which m,M be met Ea /���
prior to lauance of a Certlflote of parry. City Of LaupQIL1Ia e k -,e
Owner or authorlud agent Date TOTAL: ISSUED BY3nE—RI- T•�
OFFICE COPY