21363 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Rulldinit Proud 21 Identification I PERMIT N2 3
Buildmg Address: • 3 63 1
` a Ve' .�. -s 1 ePVUVtaUneuuwu,w..,,M,c '.
ner
CITY OF CUPERTIN6BUILDING DIVISION
j contra r`eNlIFF! uc.Na: APPLICATION I PERMIT
BUILDINC-aECMCALPLUMBINGMCCHANICAL CATEGORY CONTROL!
Arc nect n Lk.No:
°+ BUILDING �iMIT INFO '
^ QTy', r� "ELECTRIC PERMIT: , i�•` r'r PEES _" ' '
Address: �a0 C b �•� J.1� 09 1'��6 pEWTISSUANCE
LICENSED CONTRACTOR'S DE RATION ,
thereby affirmthatlamlkensed under prwLalons Of Chapler9(mmmrnc-I Am'LIANCES'RE''7DRNTTAL JOB DESCRIPTION I
ingwith SactlOn7000)of Divlslon3ofthe Bualneeand Profe.slonCade,andm PANELS (�{ Q-
Ilconse lain fuB forcpi d effect.
Lkenx Clam Contra 1!L'TS270 S - t s+l+s �..�.-l`•
Date 1�--1Contndor �%1 ���L►W> 1 WAJ1j%CV
I
ARCHITECT m.S DECLARATION Ij' -
oVER1 Ps I sQ.Fr. oRAREn 5/sQ.E.
COQC IurAentandn'"y pfaronluB be uxd as public records. '
Ob U Durand Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION I SPECLILCRCUIT/MLSC
�n 1 hereby affirm that l am exempt from the Contractor's License law fee the t
7h'Y'Q� following reason.(Sedion 7011.5,Business and Pmfesdoes Code:Any cry or TEMP,MIIIPR ORPOLEINST.
Fcountywhichrequimapec itoromu d,alter,4 pmvedemolbh,ormpalr
a anystmminpriortoltelssua sce,al.omquimtheappilanlforsuchpav tto POWER DEVICES
Ole a signed statement that he is Ilmnsed pursuant to the provisions of th e I
Contractors License Law(Chapter9(commencing with Section 7000)o1 Dlv%- SWIMMING POOL ELECTRIC VALUATION
1m.30 sion3ofthe Buslnessand Professions Code)orthat he is exempt therefm..e,
f5 the basis for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHESFIXTURES
appbant fora permit subjectathe applicant to a dvil penalty of not rrore than
five hundred dollars(550B). NEW RESIDENTIAL ELECTR SQ.M STORIES II TYPECONSTRUCTION
�I,ac owMr of the property,or my employee.with wage.sa their se•
compen.atlon,wllldothewrnk and the etmetum is not intended or O((ered.ur
p
to(Sec.7044,BU.lne.and Pmfesslon Code:The Contractors Licone La
Fd$g don not applytoan owner aproperty who Wilds or improves thereon,and OCC.GROUP RES.UNITS
whodoee such workhlmu w
li orthrgh his own employees,provided that such
Improvements are not Intended oroffered for sale.If,howavep the build Ing or TOTAL:
Improvement b sold within oneyearof complallon,the owner-W Bderwill'
tryo..�arden of proving that he did not build or improve forpurposa Of.ate.). (QTY. .t. PLUMBING'PBRMIT, FEE ' FLOOD ZONE APN
r3l,as owner Of the property,am exclusively mNracth g with Hunsed PERMIT ISSUANCE
contractors to construct the project(Sec.7614,Business and Profession Code.I ,
The Contractor's Liconm Law does not apply to an owner of properly who ALTER-DRAIN A VENT-WATER(FA)
build. or Improves thereon, and who contracts far such plojects with 'FEE SUMMARY, I
c jRt�anor(.I llansed pursuant to the Comractori License B BACK
law. I FLOW PROTECT.DEVICE , '
4,,7 am exempt under Sec. k P C far this reason ( .IQ,pr ns 1
• DRAINS FLOOR ROOF,AREA,COND. l SANITARY Y
Owner Datc RECEIPT M
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP ISCITOOL TAX Y_ N_ -�
I� 1 hereby affl.that I have P mrefiate of consent to self-inwn,Or P — ..
�qp/I RECF7[a7'P
ce'rtiiiateof worker'Comperoaionlnunnceoraanifledmpythereof(Sec. GAS EA.SYSTEM.]INCt OUTLETS PARK FIR Y_ N_
3000,tabC) �y.�� RECEIPTx
I'oit # �- � ?i.!—�'� I GAS EA.SYSTFMAVER 4(EA) BUI LDING DI VISE ON p17 ES I
Coco any U0 /{/u -
crlifledmpyelu,rc rish.d. CREASE/INDUSTRL WASTE INTERCEPTOR PLAN CI-IECK FEE
�ertiRed copy is filed with the city inspection division. '
local CERTIFICATE OF EXEMPTION FROM WORKERS' I GREASE TRAP PAID
COMPENSATION INSURANCE. SEWER-SANITARY-STORM EA.70017, Date ReC iptit
(TNPsedion need not be completed lithe permit 1s for one hundred dollars — ENERGY FEE Y N
(5100)mless.l WATER FIFATER W/VENT/Q.F-CTR � pQ —
I conify that In the performance of the work forwhlch this permit is Issued,I
I shall not employ any person In any manner so as to become subject to the I WATER SYSTEM/TREATING PAID
Workers Compensation Lwsof Callfomla,Data _
Applicant I NEW RESIDENTIAL PLMB._SQ.FT. Date Receipt#
Z Z NOTECETO APPLI CANT:If,after making this CenlflateofF empd r'you TOTAL:
2 ahould becomesubject mtheWorhera COmpnncation pro'barma M the Lobca I - -
PN Code,you must forthwith comply with such provision arthb permitahall bet (BUILDING FEE
>_ deemed revoked., I SEISMI ,FEE
W 1 CONSTRUCTION LENDING AGENCY
IL I hereby affirm that there is a contraction lending agency for the perform-I TOTAL: '` rs��PP�� L'LEC'1 IC'FE'E'
n Z case of the workforwhkh this permit is hasoad(Sec.3097,CIv.C.) \`T W
U O Lndae.Name ' 'F ) PLUMBING FEE �y,CYJ,
LL F Lndar'anddm. IQTM ' MECHANICAL PERMIT -'FEE "MECHANICAL FEE
O W lmnifythatl have read this application and statethatthealaovc inlornutlon _ FEES PAID:
lacorred.lagrceto complywith ail dty and county ordfnanm and pale fawn PEKMTT ISSUANCE
F1 relating to building construction,and hereby authorize repre scntauves Of this
N dtytoenterupontheabove-mendoned forte. ion ALTERORADDTOMECH.
Z property Peet purpose,, Date Receipt#
V _ (W e)agree to save, eats,mks and keep harmless the City of Cupertino MR HANDLING UNIT(TO 10,000 C FM)
against liabilities,judgments,mks and expense which may In anywayacerue I SUBTOTAL
agmnt sad City in consequence of the granting ofthi.permit (CONSTRUCTION TAX
(� AIR HANDLING IIMT(OVER IQW0CFM1
— .17.1`—' °f' EXHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
Sign fAppllant/Contrr Date
HAZARDO MATERIALSUISCIASURE HEATING UNIT(TO 1(D,000 BTU)Will the applicant or future bud c n
ding occupant staor handle hazardous _ Date Receipt#
m
ated.lascieflned bythe Cupenin.Municipal CodGChapter9.IZ andlhe I HEATING UNIT(OVER lOf1,003 BTU) 1LIiv,.41
I icalth and Safety Cod 3gt�on 25537U)i TOTAL:
Ej Yea No VENTILATIONFAN(SINCLERESIO) ( ISSUANCE DATE
Will the applkant I re building Occupant use equipment or device (+a
whmheMi hamrdousair<onmminants as defined by the Bay Area Air RGILERCOMP(31MOR 100,000 BTU) Y�r�IL2
Quality Management Dist d7 '
4Yes No I 1 A((I([ sj M 00
have madthe haz us nuterlais requiremenb under Chapter 6.95 of BOILER-COMP(OVER 100,000 B711) I1 {BUT S3 V ^IFJV
the California I lealth h Safety Code,Sections 75505,75533 and 25534.I
understand that if the budding does not currently have:tenant,that it d my NEW RESIDEJTIALMECH. SQ.17
rexponlbllity to notify the occupant of the requirement.whicherustberret L. O,ptyna ofA N14,16"(1
peter to issuance of a Certificate of Occopancy.
Owner or authorized agent
Data - IISSUIiUOY:�'+ �IDIQ.0�-L-1; I
TOTAL:
OFFICE COPY