20526 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuB.ddirt;Address:
20526
,11 / .G� WAL /u /fCJTG Jo�T1J !/O�K�7✓b
' 7r
9 arM: �1 / 0111:
<JgCOL S 4)66'-/�J 13yS-3 5k4 CITY OF CUPERTINO-BUILDING DIVISION
Comment'.Name: LTc.N.: APPLICATION I PERMIT
BU/LDING-ELBCTRICAL.PLUMBINGMECHANICAL CATEGORY CONTROL M
A¢hltect/Engineer. Lie No:
GTN ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PBRMITISSUANCE E] 1:1 El
CONTRACTOR'S DECLARATION
I herebyaffirenthat l am llcenaed under Emulators of Chapter 9(commenc APPUANCFSRBSTDENTIAL JOB DESCRIPTION
incense 1.Mlon force and
f Dlvfect. o(the Buslneesand ProfeulonaCode,and my
incense Ise ion(olmandeffeci. PANELS
License Clave Llaa
Data Contractor UP TO 2DO AMPS
ARCHITECT'S DECLARATION 101-1000 AMPS
ail O I understand my plans shall W used u public record.. OVER 1 O00 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E d 0 Licensed Professional SIGNS ELECTRICAL
<�Q k—�
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC .
p., IherebyalRrmthatlamlxemplfmmthe Cnntnct9ra Llcelue❑wfar the
$.. following reason.(Section 7031.5,Roinemand Professions Code:Any city or TEMP,MLTIR ORPOLE INSf.
county which requiresa pernottocowtmet,alter,improve,demolish,oreepair
q anystructure priorto It.Issuance,also mquirmtheapplicant lorsuch permit to POWER DEVICES
F file..iPA,statement that he Is licensed pursuant to the proWloes of the
G6) Contnnorb License LAW(Cha er9(commencin with Section 7000)ofDlvi-
SOS sion3oflhe Busineaand Prolemiom CWolorthatghebe"mplthemfromand SWIMMING POOL ELECTRIC VALUATION
0 the basis for the alleged exemption. Any violation of Section 70312 by any OUTLETSSWITCHE4.EXTURES 00
Applicant fora perm0.ubjects the applicant too civil penalty of net more than Q
fiveh dreddollars($500). __�, y�STO}BpS TYPE CONSTRUCTION
as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR FT. ¢//vim
sation,wBi clothe work and thestmc/ure Is not Intended or offered for
a le(Sec 706.Business and Professions Code:The Contnctols License Law
qs$ does net apply to an owner of property who builds or improves thereon,and OCC.CROUIa RFS UMTS
Fw• who does inch work himself or through his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement Issoldwithlnoneyearofcompletion,the owner-bullderwlll have
the.tittrden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
L j 1,as owner of the property,am exclusively contracting with licensed
contncton to construct the project(Sm.703.Business And Professions Code: PERMIT ISSUANCE
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wild. or Improves thereon, and who contracts far such pct
tv)es with.
CgDl�adarts)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B&P C for this reason
DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y N
Owner Date RECFET N—
_Dat
COMPENSATION DECLARATION FINTURFS PER.TRAP SCHOOL TAX Y N
❑T hereby affirm that I have a l certificate of consent d self-insure,ora RBCFM If
certificate afWorkeri Compeaatlon]aurance oracer[[fled copy thertnf(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
Polis 380D,Lab CJ ollry M M
Com any CAS EA.SYSTEM-0OVER BUILDINGDING DIVISION VISION FEES
❑pCenRied copy is hereby furnished. CREASE/INDUSR2L WASTEINTBRCE'TOR PLANCHECK FEE
F-1Certifiedcopy is filed with the a ty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 70017 Date RCCCI i#
(This section need not be completed if the permit Is foron!hundred dollars
(f100)orless0 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
[certify that Let the performance of the work for which this permit ls4wed,
I shall not employ any pelsan In any rtlanne'An
a m Wrome subject to the WATER SYSTEM/TREATING
Workers'Compenatlon La w.o(GII(ornla. Date PAID
O Z Appilcant '
Z Q NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you NEW DENIAL PLMB. SQFT. Date RCce1 [#
should became subject to the Workers''Compreastion provisions of the Labor TOTAL:
N. Code,you at forthwith mmpiy with such provisions or this permit shall be i
W > deemed revoked. a
CONSTRUCTION LENDING AGENCY- SEISMIC FEE 6
CL Ihereby aff(rmthat there b a construction lending agency for the perform ELECTRIC FEE
Z ante ofthe Workfor which this permit V Issued(Sm.3097,Civ.C.) TOTAL:
V O Lender:Name PLUMBING FEE
LL f tender.Address QTN. MECHANICAL PERMIT FEE MECHANICAL FEE
OW [certify that l have read thisappgotionand statelhat theaboveinformation
D. Isconect.I agme to comply with all city,and county ordinances and Asia laws PERMIIISSUANCE FEES PAID:
} relating to building construction,and hereby authoice representatives of this
U) - -•
H city to enter upon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH.? Date Rc'CCIp[#(We) a to am
ave,led enlfy an d keep harmless the City of Cupertino
V against bit irsjudgmente,costs dexpenseswhichmaymanywayacrme AIR HANDLING UNITED 10,000CFM) SUBTOTAL:
agalns said tyro con he grantln of Nl.peIt
7,46-90. AIR HANDLING UNIT(OVER IO,ODOCE'M) CONSTRUCTION TAX
lgesture of Appliant/Contra or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA :RIALS DISCLOSURE
Will the applicant or future building occupant store or handle hacardous HEATING UNIT(TO 100,000 BTU) Date RCCCI [#
material as defined by the Cupertino Municipal Code,Chapter 9.1 1,and the
Health and Safety Cade Section 15532(a)1 HEATING UNIT(OVER 100,00)BTU) TOTAL:
I-1 Ye. 1?Na
101he hamnlnto'r-(cont building as defined
ndby the Bayuseeciulperent Area devices VEMIILATION PAN(SINGLE RESID) ISSUANCE DATE
whicheM.hagerand air contaminants as defined by the Bay Area Air
Quality Mamgement Dbtrick?No BOILER-COMP pEOa DR]00,IXq BTI[) Ain Rn
�Ya No �'�I
avv ifrnia sopahe hazardous materialsdSort Ims
requirements under Cha pier.1 of BOILER-COMP(OVER 100,000 BTU)
the Calunderstand
t Health k Safety Code, of sum 25505,have
a t and 15536.[ J U;�I 0 6199U
understand that if thenotify
the
nupant of
the
avis tenant that it be mut
NEW RESIDENTIAL MBC{i. SQ.I'1'.
responsibility to nal(y the occupant of the rcqulrcmente which must be cont
prior to issuance of a Cenifiateof Occupancy. r•N'Of C
Owner or.utharluOFFICE COPY TOTAL:d agent Date ISSUED BY:')WWX "-'1`