20097 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification , PERMIT NO.
Budding Address: - 20097 O O 9 7
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Name: p one:
/y'9aer9N/'aawwwRallm '948. 2770 CITY OF CUPERTINO-BUILDING DIVISION s- O .
Contractor's Name: LIe.N.: APPLICATION / PERMIT
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Architect/Engineer. Lie Na BUILDINGELECTRICALPLUMBINC-MECHAMCAL CATEGORY CON7ROLM
RiFYJe9Y ZZ7 4; QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
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PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION JCC
I hereby
hScdio700(Bolamsi=3ofunder provisions of ChionesC(commm APPLIANCFSRESIDENTIAL JOB Dp�CRE'I7ON
Intmeal.1 fullf000)ofdeffeon3.fthe BuAnessand ProfesdmsCode,and my
license le in(uB force end effect. PANELS
Llrense Cku LI.0 ' l l' o
Date Contractor ����--++
ARCHITECI'S DECLARATION 201-1000 AMPS
qx Z I understand my plans shall be used as public records. O 1 t SQ.Fr.FLOOR AREA s/SQ.FT.
gw�v00 �.i r
Fz (d Licensed Professional - SI NS TRICAL` 1"
OWNER-BUILDER DECLARATION 5 CIRC[�IT•/.VfL '
owingrssor.(Satlam31.5,BsinesseComradorsLicenselawfor the
FZIQ qqqq coup yw ich req(Section rmit to o Business and Professions Code:My city or
"u( countywhich requbesapemdttocorutsuct,al[er,lmprove,demolkh,or repair 'TEMP.METER OR PO I
`'3 3 any structure prior to its lawance,also requires the applicant fee such pertNe to sa
D�Cg
Yd file a signed statement that he is Bmnsed pursuant to the provbiom of the
3µ� Contractor's License Law(Chapter 9(commencing with Section 7000)of DIW- SWIMMING POOL ELECTRIC
SOVALUATIONS sion3 of the Business and Professions Code)orthat he is exempt therefrom and D'
< the basis for the alleged exemption. Any Violation of Section 7071.5 by any OVTLETSSNTTCHESFIX'IVREs ♦ (z
0 appLart fora permit subjects the apphcanttoa civil penalty of not mo ethan L/ �/ (✓
five hundred dollars(SM. NEW RFSIDENTIALELECTR
F-1 1,as owner of the property,or my employees with wages as their sok SQ17' STORIES TYPE CONSTRUCTION
compensation,will do the week and the structure broHntended or offered for
,q vIa&,.70K Business and Professions Code:The C..t.d.e.License law
$ does not apply to an owner of property who builds or Improves theme,and OCC.GROUP RES.UNITS
EE whodoessuch workhimeelforthrough hisownemployers,provided that such
Improvements arenot intended oroffercd for.ale.ILhowavepthebuildingor TOTAL: c
Improvement h sold within oneyearofcomplalbn,the owner-builder will have
tl)9Jp en of penning that he did not build or Improve for purpose of sale.). Qry, PLUMBING PERMIT FEE
I�L ae owner of the property,am exclusively contracting with licensed FLOOD TONE APN
mntractan to construct the pmject(See 7074,Business and Pmfesslmu Code: PERMITISSUANCE
71.C.m.d.e.License Lew dm not apply to an owner of property who
build.or Improves thereon,and who contracts for such ;nplecn with a ALTER-DRAIN s:VENT-WATER(EA) 1
cgyTador(s)licensed pursuant to the Contractor's Lire.Law. -BACK FLAW PROTECT �`� FEE SUMMARY
LJ I am exempt under 10 k P C for thismason .DEVICE
Owner Doe —X- DRAINS.FLOOR ROOF,AREA,GOND. SANITARY RECEIPT
,,//� O 1 PEdSATION DECLARATION 1 ��syr�A SCHOOL TAX Y N
❑1 hc%eby Mom that I hes•certificate of consent to self-insure,or a FIXTURE"'1'ER TRAP 1• •CO RECEIPT'Y
38WIlAbc)Worken'Compesuati.n Launncemacertl(kd espy tM1ereof(Sec. GAS,EA SYSTEM-11NC4 OUTLET ,',C6 PARK FEE Y N_
C.Ilry s RECEGAS-EA.SYSLFM-OVER 4(EA) DING DI x
Cam ny � BUILDING DIVISION FEES
Fortified copy If hereby furnished. GREASE/INDU57RL WASTE INTERCEPTOR PLANGIiECIC FEE
F1 Certified copy k filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFE
(rhl.section need not be completed lithe permit b for one hundred dollars _—Date RCCeI l#
R1oo)orlm.) WATER HEATER W/VENT/m CC.1.R `�� ENERGYFEE Y N
Icartify that In the performance.fthe work forwhi h this permit is issued,
1 shall not employ any person m any manner eo a to become subject to the WATER SY9r04/TREATING
Workma Compm tton Lew.of C.Efomla.DataPAID
C! Z Applicant NEW RESIDENTIAL PCMB. SQFT. Date ReCei [#
Z Z NOTICETO APPLICANT:ILaOer making thisCertOlcateof Exempt 1. you
should become subject to the Workers'Compemadon provisions of the Labor TOTAL,—
Code,you mud forthwith comply with such provisions.,this perMtehall be _ BUILDING
W ' dcerrrd CONSTRUCTION LENDING AGENCY SEISMIC FEE L4 7_0
1L I hereby affirm that there Is a construction lending agency for the perfomm ELECT FEE
� Z ance ofthe work for which this ppeertNt lahwed(See 3097,CIv.C) TOTAL:
00 Lamise.Name M6 'Q L3.7NRC PLU IN dD
LL I- Iandce.Addresn/73 T6t~OLOOVOR- &J.is tree QTY. MECHANICAL PERMIT FEE M �
O LA-11 11
W1, AlfythatlhavereadihLappliotbnaMdatethNtheabovelnfornutlon
1 i.correct.7 agree to complywlth all cityand countyordinancesand slate laws PERMIT ISSUANCE P S AI
} N relating tobullding construction,and hereby authorize representathcv ofthk
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. D eCei t#
V _ (We)agree to save,.indemnify an d keep harmss lethe City of Cupertino P
-9 test Illli nts,costsaedexpenseswhlchrmyinanywayacerue AIR HANDLING UNIT(TO 10,ODO CFM) SU OTAL•
ag upernlbormaquence of the granting of this permit CONST CTION AX
AIR HANDLING UNIT(OVER 10,000 CFM)
SI reof Applicant/Contractor Dat_ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReCei (#
material as defined by the Cupertino M.Mdpal Code,Chaplcr9.12,and the 11 ll
Heakhand Safety Code,SMloon 25532(.)7 HEATING UNIT(OVER 100,000 BTU) OT L: R
Y. �®NN m
ill the applicant.,future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) 1�L J`-e ISSUTE.
which emit haaardous air contaminants as defined by the Bay Arca nk
ality Management District? BOILER-COMP PEP OR 100,000 BTU) -
Ya 69'N. f s
have read the hazardous materials requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU) E'S
the California Health L Safety Code,Sections 25506,25533 and 25534.1-
undentandthat bulldingdoes not currently have a tenant.that it is my NEW RESIDENTIAL MEC!{. SQFT.
resporol It not theomPa.,of the requirements which most be met
pr olss of rtificatoof Occupancy. a(�' tlB sf�tl®
`/� amide rw►►xR�l
ner or oozed agent Date ISSUED BY:
•TOTAL L
OFFICE COPY