20491 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 20491
20 60S alk Green f J2
nerscre
a :- one: A _!A' A
Tr-
1e _ -qS7 - CITY OF CUPERTINO-BUILDING DIVISION ( O
7
Cpntractor's Name: APPLICATION /PERMIT
( GU G 1bLic.No: BUfLDING-ELECTRICAIIPLUMBING-MECI IAMCAL CATEGORY CONTROL X
79 Archi /Engineer: Lic.No:
7fq -,�✓Q r4,/� �}1/'e, 1Unn A "/ QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO'
Address: PERMIT ISSUANCE ZLpU 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION -
Ihereby
affirmthat l am licensed under provisions of Chapter9(commenc APPLIANCESRESIDENITAL JOB DESCRIPTION
ingwith SeR1on70M)of Asion3ofthe Busimmand ProfenslonsCode,and my
license Is In fun force and effect ,J// PANELS
License {{__''ec) Llca 1103.' - `
Date�3�ContaRor I L GL
ARCHITECTS DECLARATION 201.1 W0AMI'S ( a"
o42 I understand my plans shall be used as public records. OVERIOODAMPS SQ.FT.FLOOR AREA f S/SQ.FT.
O
m SIGNS ELECTRICAL
Z(Oj Licensed Professional
< e.
,-<e. OWNER-BUILDER DECLARATION
tn - SPECIALCE(CUIT/MISC
Zt, owing ressr.(SatI am m7031mptfro ossa Contractors License Law for the
po following reason.($¢Bion 70315,Business and Professions Code:Any of
O 2 t- TEMP.METER OR TOLE INST.
�,� � tvuntywhlch requlrnapertNt toconstruq alter,Improve,demolsh,orrepalr
9 < any structure priorto its issuance,also requlresthe applicant forsuch permit to POWER DEVICES - )rP ,
0 e file a signed atams
teent that he licensed pursuant to the provisions of the
OgContractors License Law(Chapter9(commencing with Section 7000)of Divi-
slon3ofthe Businemand Prolessioro Code)orthathesemmpttherefmmand SWIMMING POOL ELECTRIC VALUATION
the bass for the alleged exemption. Any violation of Section 70315 by any OUTLETS SWITCHESFIXTURES /1 /Q If D f1
applicant for a permit subjects the applicant to a civil peruityofnot more Han 11 (f
five hundrcddollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STO TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
Z� compensation,will do the work and the structure s not intended or offered for '
sale(Sec.7044,Business and Professions Code:The Contractors License Law
F�$ does not apply to an owner of property who builds or improves thereon,and
^ who doessuchwork hureafforthrough hisownemployeprovided that such r OCC.GROUP RFS.L)Ix%ff5
es,
improvements are not intended or offered for sale.If,however,the building or - TOTAL: ' .uv
improvemem sold within oneyearofcompletion,theowner-bullderwill have
theIurden of proving that he did net build or improve for purpose ofsale). QTY, PL I PERMIT FEE FLOOD TANE MIN
u L as owner of the property,am exclusively contracting with Licensed PERMIT UAN
contractors to construct the project(See.7044,Business and Professlom Code:
The Contractors License Law does not apply to an owner of property who ALTER-D 'N, -WATER(FA)
Wilds or improves thereon, and who contracts for such piojects with a . FEE SUMMARY
ro�y[Rmr(s)licensed pursuant to the Contractors License Law. BAIX FLOW T.DEVICE
uI am exempt under Sec. B &P C for this reason
Owner Date IW NS. F,AREA,GOND. SANITARY Y_ N_
RFGEII'f a
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certifioInsure,ora te of consent to self- SCHOOLTAX Y N
RECEIPT X
Cerli(Icat:o(Workers'Compensatlonlnsurance ora certi(kd copytheremf(Sac. GA t G40 PARK FEE Y N
3X0p,[ab CJ PC /53 BEC=#
Poll,a J
Com alio �011( jE' SA CAS YS OVER4(EA). BUILDING DIVISION FEES
L_j Certiled rola hereby Furnished-. PLANCHECK FEE
�Certlfied ropy s GR D L wA IroR filed with the city Inspection division.
CERTIFICATE OF EXEM PIIION FROM WOR KERS' GREASE PAID
COMPENSATION INSURANCE SEWER-SANITARY-S(O Ff. Date Remi t#
(fhiewdion need not be completed tithe permit s for one hundred dollars
(5100)ml..) WATER HEATER W/VENT/F7. ENERGY FEE Y_ N_
I certify that in the performance of the work forwhich this permit is issued,
I shall not employ any person In any manner so u to become subject to the
Workers'Compewtion laws o(CalBomsWATFRSYSTEM/TREATING.Date PAID -
O Z Applicant NEWRESIDLNTTALPLMB. �.Ff. Date Repel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Amid become subject to the Worku 'Compersatlon provisions,of the Labor TOTAL-
CC Ln
OTAL:CCN Code,you muse forthwith comply with such provisions orthis permit shall be BUILDING FEE
W E3
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE r L"
Il lhembyaffirmihat there s a construction lending agency for the perforrtv TOTAL: ELECTRIC FEE
7O ance of the workfor which this permit s saued(See 3097,Civ.C.)
(,) _ Lender's Name PLUMBING FEE
LL Lenders Address QTY. MECHANICAL PERMIT FEE
O w sroIcertlythatl have read this application and statethatue above information MECHANICAL FEE
rrect.I agreeto complywith all city and munty ordinances and state laws PERMIT ISSUANCE FEES PAID:
>- N relating to building construction,and hereby authorize representatives of this -
citytoenter aPon the above-mentioned property for inspection pis rpmas. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupert Ilio . - Date Receipt#
V
against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO I0,0)0 CFM) SUBTOTAL: _
X a`ai sat C 4,In consequence ofthe grantingof this pe /��
�ie� AIR HANDLING(mit(OVER to,000cphd) CONSTRUCTION TAX
Pyof Applicant/Contractor Data 'r LAHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant dr future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BM Date Recd t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the -
IlealthandSafety Code Section 25532(a)7 - HEATING UNIT(OVER 100,x00 BTU) TOTAL:
ElYu . M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE (Y 6,
which emit hamrdom air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,0(10 BTU) �I`RRD
Yea No
have read the haves mus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) " U
.l UUNQ �x9eses90n
the California Health&Safety Code,Sections 25505,25533 and 25514.1 V
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff.
responsibility to notify the occupant of the requirements which must be met
prior to issuance d a Cerd Orate of Om Fancy. t !4i Cf rapertinn
Owner or authorized agent Date rorn1: ISSUED BY.. ku U J
OFFICE COPY