20909 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification G PERMIT NO.
em1��a n: /go 7a_.Of 7/113 � � 20909
_ I a T� � �4
a one: APPLICA lT=9K1n1'AL DA IL
CITY OF CUPERTINO-BUILDING DIVISION
Centractm&Nan,e: Lic.N. APPLICATION / PERMIT �J l
Archlted/Engineer. Lk.N. BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL//'UU!n
•QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO''LL
Address: IISO7 5a1VerS' ernCt U N n.00 � "' yLICENSED CONTRACTOR'S DEC TION 1� S0'
I hereby affirm that l am licensed under provisions of Chapter 9(commene, MP AN L'- is
JOB DESCRIPTION
ingwlth Section 700@of Divlelon3ofthe Businnsand Prefesalon.Gde,andmyO rs _
licar.I.lnfullforteandeffect. P '\,//,� P
License Class Lk.N
Data Contractor
ARCHITECTS DECLARATION 201-I
mO p I understand my plans shall be used n public rerords OVER SQ.FT.EI.00R AREA S/ FT
Licensed Professional SIGNSELECTRICAL ��O l Ipy,'LJI -24 `
X63 OWNERBUILDER DECLARATION SPECIALCRCUIT/MPS
Iherebya(flrm tContractor'sx
ticent exempt from the Contractor's LlttnLew forth. (1�f� •CJ•p
o (olWwing rea&on.(Sedion 701L5,Buanea and Pro(eabna Gds:Anydty or l;J J
Ki"'� county which requires a permittocorstmct,alter,Improve,demolish,orrepalr TQ.4P.MEI'FIt OR TOLE]NST.
any rtmeture prlorto ltsissuance,also requlresthe applicantfonuch perm[tto
afile a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
3 I Contractor'sLicerseLaw(Clopter9(commencingwithSection 7000)ofDivi- gWBfedNCPOOL ELECTRIC
SOS don3o(the Busineaand Prolcalory Code)orthatheisexemp[therefromand VALUATION
�^ the basis lar the alleged exemptlon. Any violation of Section 70115 by any t�Q I Q 30
OS OUTLE7SSWITCF{FSRJCfUftpS
applicant fora permit subjects thea ppllcanl to a civil pmulty,of not more than 11
$ five hundred dollars($500). NEWRESIDENTTALELECTR STORIES TYPE CONSTRUCTION
F11,as owner of the property,or my employees with wages as their sole a �'�'
compensation,willelothe work andthe structure is am[mended or offered for l
ale(Sec.7044,Business and Professions Code:The Contractor's License Law s + V
$ does not apply to an owner of property who builds or Improve&Iherron,and /
EEEE whodoes suchwork hlmatforthrough hlsown employees,provided thatsuch OCC.GROfID RES. (.
Improvements am not Intended oroffered forsals.If however,thebulldingor TOTAL:
Improvement issold within oneyearof completion,the owner-bulW erwlll have
e rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLODDZONE APN
I,a owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE .•T
ontradomn to corawd the project(Sec.7044,Business and Professions Code: `&(m
The Commerce.License Law don not apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
belld.or Improve.Everson, and who contracts for such projects with a
cgR(pdor a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B k P C(or this reason
OwnerOUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RECEIPT WORKMANCOMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
0T ae of affirm that I have a le rata of consent d apythaure,ora RECENT M
\, cenlflcabC.) rkeme Compersattors]nsuranm oracertl(led ropythemof(Sec. GAS EA.SYSTEM-I INCA OUTLETS
Poli leis C.) PARK FEE Y_ N
_ .Policy N RECEE'T X
Com an GAS EA.SYSTEM-OVER 4 BA)
YBUILDING DI VISION FEES
Certified copy is hereby filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy V flied with the city inspection division.
CERTIED
FICATEOP EXEMPTION FROM WORK ERS' CREASE TRAP PAID Cr—M—Ro 5W'>_
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200EI' Date Recei tN �it
(Thlasectlon need not be completed It the permit is(orone hundred dollar.
($100)IorrBless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I llnotempthat in employ
an person
Is e of any he manner so as to b co eertNt is laved, —
I shall not empty any person f any nonan so n to become subject ro the WAT7R SYSTEM/TREATING Z..�—I d ((��•f.t�Z
Workcre'Compenation Iowa o(Call(ornla.Date PAID
CI Z Applicant NEW RESIDENTIAL PLMO.
FT.SQ Date Remi tN -{los C70
Z O NOTICE TO APPLICANT.If,aaer making this Certificate of Exemption,you
should beconsinb)ect to the Worker.-Compensation provisions of the Labor /^..tn..�� TOTAL: a
tlI Codgyoumu.tforthMthcomplywlth.uhprovisloroorthis Ne t.hallbe 27.s7 y�
deemed revoked. BUILDING
Ibl7!.
III
G CONSTRUCTION LENDING AGENCY SEISMIC Civ.C.)C.) TOTAL _
Thereby affirm that there Is a corstroction lending agency for the perforin 137s ELECTRIC FEE ` 7&
Z once of the work which this permit is Issued(Ser.3097, :
O O Lender'.Name PLUMBING FEE
LL — Lendefs Address QTY. MECHANICAL PERMIT FEE � 7-Z
O W Icertitythatl have ieadthisapplicationand statethattheabovelefornatlon MECHANICAL FEE 7a
IL ismrrect.I agrmto comply with all city and county ordinances and elate laws PERMIT ISSUANCE (ZIC0 FEE—PAID-
>_ W relating to building construction,and hereby authorize representative.o(this
(_ Z city to enter a pan the above-mentioned property for inspection purposes. ALTTRORADDTOMECH. Date ReCCI tk -
z (We)agree to ave,Indemnify an d keep harmless the City of Cupertino
against Liabilities,pdgmenta,cants and expenses which may In any wayacerue AIR HANDLING UNIT(TO 10,ODO CEM) SUBTOTAL:
.gal Id Ci io segue of the granting mthly permit —'
AIR HANDWNG UNIT(OVER 10,"CFM) CONSTRUCTION TAX
ig.Wra.f Appllant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIl the applicant or future building occupant store or handle hsardoua HEATING UMT(TO]00,0008TU) Date RCCCI IN
naterisl as defined by the Cupertino Municipal Code,Chapter 9.1 Z,and the
Health and Safety Cade,$ too 25532(a)7 HEATING UNIT(OVER 100,000 BT(1) TOTAL•Z .Lt
f 1 Yen --V—LN.
111 theappliant future building occupant use equipment ordevims VENTILATION FAN(SINGLE REED) ISrjIJg7V( MATE
hich emit hararduus airmntairmnls as de0ned by ted Bay Area Air ��-!y1'Cp -
QualityManagementDistrld7 BOILER.COMP(3HP OR loo'liq BTU)
44 Yea
have mad the hazy us materlais requirements underCM1apter 6.95 of BOIL[R-COMP(OVER 100,000 BTU) ( IjtQ
Lt.Glitornla Health
f4
Code,Sections25505,25533 and 25534. I
and creta od that if the Ilding does not currently have a ten ant,that Itis my NEW RESIDENTIAL MEC]{. SQ.FT.
mnporsibllitytond[ythe mmpa at of the roqulrements which moat be mat ! � �
rior to_uxnc ofa Tcruficate of Pan 9 '2 Ck 00
—/�
On, authorizedagent Date ISSUED BY: L
TOTAL: !3 t
OFFICE COPY