20441 ...LICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tluildin Prn'm ldentlflnt n PERTXNOa PERMIT NO.
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1 Addmss: t C'V 1�'
VALLco FASN=oN 1PARK SPACE 'S t00'7 13 CA. Lim
a aces: C/0 '•X 11hsS 3f 32y� 300 't
CM-z&=N'N' COOKxE. co �aN CITYO�CUPERTINO-BUILDINGDIVISION
Cmtanor;Name: Uc.No: APPLICATION / PERMIT FES, to Tw 199
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Ot)T To SSD BLIILDINO-ELFGTRICAT PLUMBINGMECHAMCAL CATEGORY CONTROL#
Arch ten/Engineer. Lk.Na
ENNE'-M1L U S 04071 Q.ly ELECTRIC PERMIT FEE BUILDING PERMIT INFO
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Address;%'ZSTAVECOA,c, R9 . Del I C94 ,,I PERI.unSSUANCE 15
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LICENSED CONTRACTOR'S DECLARATION e4.
I Mrebyaffirm thatiem Rcensedunderprovlsionso(Chapter9(c £� APPLIANCES-RESIDENTIAL JOR DFSCRI ION
Ingwith Sedion7D00)ofMA.ion3ofthe Businessand PnfesslonsCodW my COO4CS
license is In fill force and effect. PANELS OR=GNL
s. AE CO.
License Clan Llc.p
Data Contractor C0ovc-CE, 5TOIRE
ARCHITECTS DECLARATION M-l"AMPS
W'Z I understand my plaru shallbe used aspublic records OVER 10DO AMPS SQ.FF.FLOOR AREA $/SQ.FT.
O
NO Licensed Professional SIGNSELFGTRICAL /(Q
6 OWNER-BUILDER DECLARATION SPECIALCIRCNT/MLSC
Iherebyaffirm that lam exempt from the Contractor;Limnsa law for the
Z O..' followleg mance.(Section 7031.5,Business,and Prefesslons Code:Anydty or
TEMKZF"9 ceuntywhkhmquimsaper ttommtmMalter,improve,demolbh,ormpair P'MEl'ERORI'OLE INST.
1 anystm=mpr rtoitsbwancsaLwrequimtheappliantformchpemdlto Iy
file a signed statement that he is licensed pursuant to the proWlom of the
POWER DEVICES
SOSContractor;LLicense,Law(Chapter 9(commencing with Section 7000)of Divi- A
slon3ofthe Businessand Prof� iors Code)orthatthelsexemptthemfmmand SWL4[MINC POOL ELECTRIC O O
O S he bases for he alleged exemption. Any violation of Section 7MIS by any ETSSWITCHt5FlX'IURFS ^� M�
applicant for a permit subjects the applicant to a civil penalty a not more than LV s
c. five hundred dollzn(5500).
R NEW RESIDENTIAL ELECTR SQ.Fi. SFOWES TYPECONSIRUCTION
I,as owner of he property,or my employm with wage as their suis IV/
compensation,wdldotW work,andthestrunure es not Intended or offend for ALT6aYR7ko
9 ❑ sale&c.7044,Busla sta and Predications Code:The Contra tor's License law
Rik
5� does not apply to an owner of property who builds orimprovesthereon,and OCC.GROUP RES.UNIT'S
who does such work hureadforthrough his own employees,provided that such
improvements arc not Intended or offered for sale.If,however,the building or
improvement essold with to one yearofcomplatios the owner-builderwill have
thetrrden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
LJ L,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to mrstruci the project(Sec.7044,Business and Profassbns Code: PERMIT ISSUANCE
TM CoM eador's License Law docs not apply to an owner of property who ALTER-DRAIN&VENT-WATER
builds or Improves themon,and who contracts for such p5ojects with a FEE SUMMARY
cgIltT+eor(a)licensed punuaec nt to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under SB& P C for thin reason
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
lhvner Date RFGm'f#
Wm ORKMAN COMPL'NSATION DECLARATION FO(771RESPEJZ , �� SCO{(3pL TA% Y_ N_
01 hemby dorthat I have a certificate of consent to self-insure,ora RECEIPT M
3900,Ueo(Workeri Compensationiwurance ora mrtl(kd mpythemo((Sec. GAS EA.SYSTEM-4 INCAOUILETS PARK FEE Y_ N_
3800,lab C3 RECEIPT#
Policy a GAS F.A.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
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CertlRed copy Is,hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCenified copy es filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP �— PAID
COMPENSATION INSURANCE SEW FA SAM.I.ARY STORM FA 2(pFl. R
(Thesseetion need not be completed tithe permit b Toro.hundred dollars
(ItlMorless.) WATQ4 HEATER W/VFM/D.ECTR ENEI "E Y_ N_
1 cemlythat in the performance of the work for which this permit Is bsued,
1 shall not employ any peneso in any mann so as to became subject to the WAT17 SYSTEM/TRPATING
Workers'Compensation laws of Cal�p . ate P ID
Z0 NOTICnt�! NEW RESIDENTIAL ELMS. SQ.Fr. Date ReDl tp
O NOTICE TO#PLICA :.,If,, //�1l�ppssaa'JrJ1l gthis Ccrtl({ sof Exemption,you
shmldbccomesubjectt h o Campers.s(�pv eslmsmfthe Labor TOTA
F" (n Code,you must forth ply withsu ryp(�(o`sor his permit shall be
— deemed revoked. BUILDING FE'
W �
tl � coNST I VC AGENCY SEISMIC PEE _
Z IherebyafOrm that there b a col7{pkllan lending agency forthe perform To ELECTRIC FEE
anm of the work for which this permit es Issued(Sec.3097,Cie.CJ
O Lender;Name PLUMBING FEE _ /^
P Lender'.Address QTY.I MECHANICAL PERMIT FGE MSCI-IANICAL FEE
I cartilythat l have read thisappliation and statethat the above information — —
is comet.I agree to comply with all city and county ordinances and state laws I'FRMTT ISSUANCE FEES PAT
relating to building construction,and hereby authorize representatives of this
city to enter upon the above.mentioned property for inspection purposes. LTF220RADD TO MECH.
(Wr)agree to save,indemnify an d keep harMeo the City of Cupertino Date Receipt#
against llabi0ties,judgment,mstsand expenses which may In anyway..e AIR HANDLING UNIT(TO IQODO CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
NR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigrsture of Applicant/Contractor Data E%HAUS'r HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oro pant store or ba nd le havardoes HFATING UNI'r(TO 100,000 B'IU) Date Cel t ��
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
f ieahh and Safety Codree SSedion 25532(a)7 HEATING UNIT(OVER 100,000 BTU)) T
Yea
No
�WIE heapplicant orfutum building occupant use equipment ordevices VENULATION PAN(SINGLE RESID) Is$�$rUANCE DATE -
whichemithavrdousair contaMoantsasdefinedbythe Bay ArcaAir r (A u I�
Quality Management Dist ring BOILER-COMP(3HP OR 100,000 BTU)
Yn 1❑.No
4haveraad Keith&Safety
fmuter,Se tions requirements under Chapter 6.95 of BOILER COMP(OVER(00,000 BTU) APR 18 1994
c.Ulifomia at if the
&Safety Cods Seniors 2550.5,21533 and 25534. 1
uspossidersta nlly to notify(he
ing doesoccupant note mqulyhaveat hihnnhatitbmy NEW RESIDENTIAL MECFi. 5Q.F7
mor to is0itylo of aCccocte ofCcuof pacy- ipnt. non must be rpt C11YUt UUrtNUP ,
priormtasuance mfaCertlficate of Ocmpanq. Lyp�
ORscrzl.+aL- cepuCS� (,prs4P Br �
Own pip loge T - / ISSUED BY: ( 1
i` OFFICE COPY