20794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:S 20794 OI ^ 4
t.0. [ "✓liJ CITY OF CUPERTINO-BUILDING DIVISION c
cn Tad° M'Ta�me: N/°! APPLICATION it PERMIT D
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROLIt
Archlte t/Fsglneen Lk.Na:
QTY ELECTRIC PERMIT FEE BUILDIIN/,G PERMIT INFO
Address Or'r'l.7 PERMITIS5UANCE .D� p ❑ ❑
LICENSED CONTRACTOR'S DECLARATION !J'
I hereby affirm that lam Bernard under provisions of Chapter 9(commenc APPLLANCESRESI NHAL JOB DGSCRIPM N
IngwithSed1on7000)of Dlvision3ofthe Buainessand ProfeulonsCode,and my t 1 AOD
Iimnselainfull meanddfed. PANELS6)--1•TYv J /NI
Llanse Cl Lich 04
Date Contractor
ARCHITECTSDE public ION 20 ER10�AMPSrcOZO I underetand my phru shall be used as LA Rc records OVER 10SQ.IT.ILOOR FA $/$Q.FC.
otj Licensed Professional a SIGNS E
�n leu OWNER-BUILDER DECLARATION SPEC CIRCUI 1
zp„vIU ' Ihembyaffirra that l am exempt from the Contractor's License law for the
following reason.(Section 7611.5,Business and Professions Code:An d or
FgC countywhich,quiresapermtttommu d,alfenlmprove,demdlsh,orrepair TEMP' L I
,,551 any atruamrepdorto lU Lwunce,alw requlrcatheappBont forsurh permit to POWERD
file a signed statement that he is licensed pursuant to the provlsiom of the
0 a. Contractor's License Law(Chapter 9(commencing with Seton 7000)of Divi-0in 3ofthe Business and Professions Code)orthat he is exempttherefromand SWIMMINGLELE VALUAT{QN
the basis for the alleged exemption. Any violation of Section 70315 an
appecant for a permit mb)ets iheappbcant too civil panshyo(not mom than OUILETSSWI IO%'I'URFS r
five hundred dollars($.500. NV—
NEW RESIDENTIAL ELECTR FT.
1,as owner of the ro BO. W IS TYPE CONSTRUCTION
�n a, party,ci my employees with wages as their sole
compensation,Ruainew..dwill dotha, Prrk,aedthetrude:Th Co.hameot Intended or License
dfar
Law
O dile(Sec.apply
to alnow and Profession Code:The Contractors Llceve Law
whoddoes ot apchy rkhan w lorth=gproperty who builds oy"spv idh toa,and OCC.GROUP RES.UNITS
GG wnod rZifth am net mself edorofgh hleowne.If,ho a, er,thedth twch ing or
improvementi am net Intended earofredforaale.th owevep deer ill have TOTAL:
Improvement laeold wlthinoncyearofcompldloMthe ownenbullderwlll have
t)Ir„JT.udenof provingthat he did nmbuild or 4npreve for purposeofeale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
Lf I,as owner of the property,am exclusively mntrating with Ilansed PERMIT ISSUANCE
cintractvrs to mratrut the project(Sec 7074,Business and Professions Code:
The Commum's License Law does nor apply to an owner of property who ALTER-DRAIN kVENT-WATER(GO
t builds or improves thereon,and who contracts for such ptojet -
a with a -
cgR{Tator(a)licensed pursuant to the Contradoes License Law. FEE SUMMARY
Ll l em exempt under Sec B k P C for thb reason BACK FLOW PROTECT.DEVICE IS
Owner DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y QUT.N,. .
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION pyyTURES,I'FR TRAP SCHOOL TA% Y N
hereby affirm that I have a certificate of consent to self-Insure,or RECFIITf k
Ifiate of Workem'Compemation Insurance ora certified copythermf Gre. GAS EA. INC40UTLE7S
OO,Lab C.) PARK FEE Y N
PoIIcy N117Y'
RECEIPTN
GAS EA.SYSTEM-OVER 4(EA)
.- BUILDING DIVISION PIiES
Certiied copy V hereby furnished.
C
Certlfietl copy V filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE. SEWER-SANITARY-STORM EA.200/1' Date Recei t#
(This section need est he compiled lithe permit L9(Drone hundred dollars
(81I carifess) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
lartify that In the performance of the work for which this permit lobated, —
I shall not employ any In any manner sat u to become subjet to the WATER SYSTEM/TREATING
Worlicra'C°mpensatl°n Laws
aws of California,Date PAID
ZO NOTICE TO APPLICAM:I(,after making thisCertBlrate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Daft Recei t#
Ha hmldbemmesubjcdtothe Workers''Compemtim pnevislomofthe Labor TOTAL:
N Codayeu res at forthwith comply withauch proWimamilds pecrrdtahallbe BUILDING E S
> Beamed revoked.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE r S'
Z Ihercbya(firm thattherelsa conmtmdion lending agency for the perform. TOTAL- ELECTRIC FEE Q
V70 ananrehework rnrwMenmmpermit t tswnd(Sec,3097,Civ.C.) PLUMBING FEE
Lander.Name
LL 1- Lenders Address QTY. MECHANICALPERMIT FEE MECHANICAL FEE
,OW lmdifythallhavereadthieappllmtbnanddatethattheabovelnf°rmatlon
6 Ismrred.]agreeto comply wlthalletyand muntyoNlnancea and maielawa PERMIT ISSUANCE FEES PAID;
} relatingwisillding construction,and hereby authorize representatives ofthb
H V) dtyenterupontheabavcmentloaed property for Inspection purposes. ALTERORADDTOMECH,
V — e)a!Apn
to save,Indemnity an d kap harmless the City of Cupertino Date Recelpt#
ag Ilaie df rmnta a and expenses which may in any way acme AIR HANDLING UNIT(TO 10,MO CFM) SUBTOTAL:
ag net aal ' mesa ace oflM glanting of this permit.
l AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTIONTAX
t/CmAc o Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will the applicant on future building occupant store or handle hazardous HEATING UNIT ITO 10D,000 BTU) Date RCCCI t#
rnatemil as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iiealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER IDg000 BTI!) TOTAL: D0
71 Yea No
Will the applicant o future building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSI]AyTATE
which cont hazardous a4 crnlaminants as defined by the Bay Area Air FN.a.//,L�1T
'� Quality Management District? BOEER-COMP OHP OR 100,f1(p BTU)
ph Yea, No
avonui the haaa �et rCode,da Semon 2555,2553er ad 2553rg.95 of BOEER-COMP(OV1R 100,Of108N) JUL
4101$
the OliMdla Health&Safely Code,Sections have.Sand,that
�j,l/ ( (,J k�
undo dthaii(the building does not currently havealcnanq that itEmy NEW RESIDENTIAL MECH. �.PT.
repo Ilty ion the ocmpant of the ratio tremens which=at be mei
prior Issuance I o(Ot4panry.
Own aulhcal gent ISSl1ED6 :
TOTAL:
OFFICE COPY .