20831 APPLICANT TO FILL IN IN FORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: - 20831
B/ 2 SA/Lvate . . R
r-ovmer Aa^G /N Aui►N i,riove. VAIL
CITY OF CUPERTINO-BUILDING DIVISION A
nno-adnFaN=me' Lt=pN= APPLICATION / PERMIT' R O
I 1 tp /NC. O O { f� CATEGORY CONTROL
Aretated/Engineer, L
1 k.Nu e[11LDINGELEC7RICALI'LIIMOINGMECHAMCAL G1S5,
PERMIT,INF 1
0•
J AN QTY''. LLECTRIPEItl11IT FFE
or EL PLUMB
Address: 7 � /� /�a+• PFR ITISSUANCE � ❑ - ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthzt l amllcensed under prwislons of Chapter 9(mmmmo- APPLIANCES-RESIDENTIAL. JOB DESCRIPTION -
ingwithSecdon7000)of DIvixim3 ofthe Businessand Pro(esalonsCode,and my
" license la In full form and effect �/ PANELS '
Llrense Chse�LLic.#�Jm;;;
Date" Contratbr
ARCHITECPS DECLARATION' 201-1000 AMPS
q�v aO Zp Tunders[and my plansshallbeusedaspubllcrecorde.' _ OVER 1000 AMPS - - SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION a• �L
Ii, Fi7SPECIAL CIf1CUIT/MIST .
i., [hereby alfimm nthatlaexempt from the Contractor's Llrense Law forthe _
Z O following reason.(Section 7031.5,Business and Professions Code:Any city or
F i:,,r� TEMP. OR INST.
cii
c #
wntywhich requires pemNtromnstmct,atter,improve,demolish,orrepalr
any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
^aye O ec Contractors License Law(Chapter 9(mmmendng w8h Sedlon 7OOD)of Dtvt- VALUATION
q� SWIMMING POOL ELECTRIC
-HIla O thesiobasis for
the alleged
ProfessionsAny viothat lation if exempt therefrom and
o the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESHXCURES I 1 I Q O
applicant fora permit subjects the applicant to a civil penalty ofnot morethan u `
five hundred dollars($5W). SQRT, STORIES TYPE CONSTRUCTION
- t' NEW RESIDEMfIAL ELECTR
444444111111 ❑I,as owner of the property,or my employees with wages their sole
1.1&a. 0K will do Business sort k,and the et odure Is Contractoret Intended or icatured for
Law r
q sale(Sec 7614,to Businesssort
property Code:The Contractors Llrense Law
does net toanownerofprough who builds
mporimproves
ovidedthatsuh - OCC.GROUP RE9,UNTTS
who
ovementsa not Intendedorwgh his own ale..Ityees,providedthatsuor
improvements tinlendneyearferedfor sale theh er-bugderwdI have TOTAL:
Improvement proving
tht ha didetbuil porimrove fopurpse of sale.). i„y � ,
tl�,burden ofpmving thathedict not build or improve for purpose of sale.). Q7y)z=�tt, rt:"j;1f1'(BiN(r"1?la]tM�rc .. , ' ';tats FLOOD ZONE APN
jJ L as owner of the property,am exclusively contracting with Ikeneed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: ,
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon -
an
, d who contends fee such ptojects with a
- oop�l!lTadems)licensed pursuant to the Contradrns License Law.
=LJI am exempt under Sec: B&P for this reason BACK FLOW PROTECT.DEVICE OUTSIDEFEES
Owner. - - Data DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RECEIPT If
❑I hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES PER TRAP SCHOOLTAX Y_ N_
certificate of Warkeri Compensation Insurance or a certified copy thereof(sec. RECEIPT If
3800,Lab C.) GAS F.A.9YSTEM-1 INCA OUTLETS PARK FEE,.,• Y_ N_
Policy# - - RECEIPT#
GAS EA.SYSTEM-OVER 4(EA)Com any � BUILDING DIVISION FEES
r ffCekified copy is hereby famished. GREASEANDUSTRL WASTE INTERCEPTOR LANCHECK FEE
❑Certified ropy Is filed with the city Inspection division. #'a(. Q� Q
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID I �\tax/ 911 U`�
COMPENSATION MSURANCE gEWE&SANITARY-STORM EA.200FT. Date Recei t# 11
(This section need not be completed If the permit&for one hundred dollars
(810 WATER HEATER W/VENT/ELECTR, -NERGY-FEE Y N
I crdify cekifythat in the pekormanre ofthe work for which this permit is Issued,
I shall not employ any person In any manner w as to become subject to the WATER SY57'PM/TREATING
Workers'Compensation Laws of Califomla.Date - P
ZZ Applicant NEW RESIDENTIAL PLMg.__SQ.FC d Date
O NOTICE TO APPLICANT:[LaRer making this Certificate of Exemption,yell
should become subject to the Workers'Compenaation provisions ofthe Labor TOTAL: LkL*Ms
CC V2 ' Code,you must forthwith comply with such provisions orthis permit shall be
Uj j deemed revoked.
CONSTRUCTION LENDING AGENCY $ET IC PEE
a Z Ihereby affirmt)ut there is a construction lending agency for the perform, TOTAL: E •C'I'RIC FEE
.� O anre of the work for which this permit is issued(Sec.3097,Civ,Q
V Lender's Name - 1 a LUMBING FEE
IvIECI''iANICALIPBRINtTt ° MECHANICAL FEE
LL H Lendels Address QTY t'�' ° ..
OW Ireklfythatl have readthbapplicstlonand tlatethatthe above information
1 hiconect.l agree to complywith all city and county ordinances and gate laws PERMTr LS.SUANCE FEES PAID: Q
W relating to building construction,and hereby authodze representatives ofthis .
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH, \tE _- seer #
Z
Z. (We)agree to save,indemnify and keep harmless the City of Cupertino
against lUbilltles,judgments,mrtsand expenses which may,in anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
aSamtsald C' neons ence o(t granting of this permit
� 2 7 64/ AIR HANDWNGUMT(OVER IO,000CFM) CONSTRUCTION TAX
Signature of Appcant/Contract a� 115t. V EUHAUST 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 .ROCeI f#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Rea lth and Safety Code ion 75532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea
JK .P ,. ,. - .
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID), ISP'AVWE.DATE
which emit ha tsedous air contaminants as defined by the Bay Area Air
Quality Mamgement Distr BOILER-COMP OHP OR 100,0000TU)
Yes �NnV z v,�g90
4
have iehdihehua ousNo me
materia6mquirentsunderChapter6.95of BOILER-COMP(OVER 100,DO0 BTU) ,
the W tifernla Health&Safety Code,Sectioro 75505,25533 and 25534,1
understand that if the building does not currently have a tenant,that it is my NEWRESIDEMIALMECH,' SQ.FF.to
_ ��4{ts� ,,.�a4.(!q a m!11
responsibility onoil(y the occupant.(the ryryqulremente which must be met Wq i%I I r •
priormibfll eofaCertlf to_ O/ccfuy#Cnry. Q '
Ownerorauthoncedagard ! jPatc - ISSUED BY:
TOTAL:
OFFICE COPY