20508 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Nuildln Prr'en Identlfiomm� ' - PERMITNO.
Building Address: 20508 ,
7l8 0 O (�
L G .
.vInel. one: A A
CITY OF CUPERTINO-BUILDING DIVISION
°n atlmra aces: Lk.No: APPLICATION/PERMIT - ��
/�Y) i -er CfnN BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROLY
A itect/ glneer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: — PERP TISSUAN ❑ ❑ El
CONTRACTOR'S DECLARATION ,
IMrebyaffirmthatlam Bcensedunderpr isiomor Chapter9(co me APPLIANCES D L JOB DESCRIPTIONingwith Se on7000)of DiAsion3ofthe Businessand ProfessionsCode,and my
license is In full f and effect. PANELS `� �
lice lass LIff Y y 2 Z 2 /G
Date - Contaanor�'!�%N !�rJ�/
ARCHITECTS DECLARATION 20t-1000 A.NI'SMI I
Z I understand my plans shall be used as public records OVER 1000 AM SQ.FT.FLOOR AREA $/SQ.FT.
O
C U U Licensed Professional SIGN
G OWNER-BUILDER DECLARATION SPFLIA /M
�.., Iherebyaflrmthatfamexemptfromthe Contractor's License Law for the
ZO-'� foemwing reason.(Section7m1.5,Businessand Professions Code:) ycl or
OZF.µ9 TEMP.M OR POLE IN
F�pppp countyctum requlresa pemdt to coatauftes th,improvgdemnlbh,orreit 1.
<, anystacture prize to its Lvsuan[G abm requlresthe applicant for such peat t e ppyypg DM
4 file a signed statement that M is licensed pursuant to the provisions of the
Contractor's License law(Chapter 9(commencingwith Section 7000)ofDIW-
FbO ston3 oftheeusiness and Professiora Cede)orthat he b exempt themfromand SWIMABNC POO EC C- VALUATION
yy S^$ the basisfor the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCITESFIXTURES
pQO
applicant fora permit subjecusthe applicant to a civil penalty of not excirethan
as five hundred dollars rof the
DOL
pro SQ,FT, STORIES TYPECONSTRUCTION
pf,,5 [4cNEW RFSIDENRIAL ELEC7R
c❑I,as owner o(thc property,or my employees with wages as their sole
ompensation,wBldo the work and thestructum is not Intended or offered for
Osale(Sec 7044,8u,Ircm and professions Code:The Contractors License Law
$�
does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUI' RFS.UNITS
who does such work himself or through his own employees,provided that such
improvements are not intended oroffered for sale.Hhowevegthebuildingor - TOTAL:
improvement issold within one yearofcomple0on,the owner-bullderwili have
th�e +rdenofpmving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE- FLOOD ZONE. APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to coaW ct the project(Sec.7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT
_ Wilds or Improves thereon, and who contracts for such projeM -
with a WATER(EA)
,�t[[a0 (s)Bcens°d pursuant to the Contractor's License Law. 'FEE SUMMARY
IJ I am exempt under Sec B& P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N
WORKAN COMPENSATION DECLARATION RECEIPT
M
❑I hereby affirm that I have a certificate or consent to self-insure,or a MTURE" PER TRV. SCIIOOL TAX Y N
ennifiate of Workons ComperustionInsre
urance or a certified copytheof(Sec. RECEIPT X
GA
3800,I.b C.) S EA.SYSII]H-1 INC.40ITILEIS PARK FFP Y_ N
RECEIPT Y
policy Y GAS FA.SYSTENFOVER 4(FA)
Cum BUILDING DIVISION FEES
[Certified copy b heed with t ecity - GREASE/IIYDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�IPertif ed ropy b/i4d with the city inspection division.
�F CERTIFICATE OF IX'EMIFTION FROM WORKERS'. CSE TRAJ? PAID .
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1' Date Recei t#
Tfhlswdion need nu W complued if the permit b foroa hundred dollars
($10()orless.) WA.T.FRrffA.]Tx W/VENT/ELECTR ENERCYFEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/IRFA]lNG
Workeri Compensation I.waof California. Date PAID
-
zZ Applicant NEW RESIDENTIAL['LMB. SQFT. Date Recel tJf
Z NOTICE TO APPLICANT:If,after making this Certificate Of Exemption,you
should become subject to the Workeri Campensmlon provisions of the Labor TOTAL:
~ N Code, must forthwith comply with such nAdom orthb permit shall be
� j deereed revoked. Py Pro BUILDING FEE
W — CONSTRUCTION LENDING AGENCY ' SEISMIC FEE
IL IbcrebyafRrm that there b a romatrurtimn lending agency for the perform- TOTAL: ELECTRIC FEE
7 Q ec.arm of the work for which this permit is Issued(Sm 3097,Civ,CJ
Lender,Name - PLUMBINGFEE
LL 1- Lenders Address QTY. MECHANICAL PERMIT ITE . MEC
O W v
HANICAL FEE
• 1 cercifythat I have read thisapplicition and statethatthe above information -
ert.l agree to comply with all city and county ordinanceseit state laws PERMIT ISSUANCE FEES PAID:
}'IL y relating m se building construction,and hereby authorirepresentatives of this
(— U) city to enter upon the above-mentloned property for Inspection purposes. ALTERORADI)MMECH. Date Receipt#
(We)agree to save,Ind comfy an d keep harmless the City of Cupertino
V against liabilit jsdgna ,cmNsand eapenxs whkh may In anywayattme AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
ago instsaid t In ro9�. ftM granting&thls peanut.
rl ///.tAceJ y ^� AIRHANDUNGU IT(OVER10,000CIM) CONSTRUCTION TAX
Sigato Appfi/anti//Co_ntr`actor DaDate F UST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT CTO 100,000 BTU) Date Recel tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Healthand Sifcty Code Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: e
❑ Yes• I]No
Willthe applicant or Future building occupant meequipment ordCVLMS VENTILATION FAN(SINGLE REBID) PAMEDATE
which emit havrdous air contamiantn as den red by the Bay Area Air
Quality Management District? BOILFR-COMP QHPOR 100,000 BTU)Yes J 1`� 0A U
1995
have read the haves oN No Z materials requirements underChapter 6.95 of BOILER-COMP(OVFR100,00(i
the Califomla Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met Ll�i40f cum=
priortoiss ofa teof Ocapancy. '
-71�;, —:� W -e
q
OvmcMFauth.mmd algent Date TOTAL ISSUED BY
OFFICE COPY