21884 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldinc Project Identification I PERMITNO,
Building Add rev: `21884 I`
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62—,-2/y CITY OF CUPERTINO-BUILDING DIVISION
�� ContractLOr''e'Name. �F (7 �, 'L Lie.No: APPLICATION I PERMIT
BLULDINGELECTRICAI MUMBINGMECHAMCAL CATEGORY CONTROL X
AmM14tecifFsg4neea _ L1c,N 1 t ,I, ,, t I IBUILDINC ERMIT,INFO
Q>"! ELECTRICPERMIT FEE,"' ". ..
- - " - new G.CQ7�Pf.L'Ff9�'- �
Address: Z3C/Y9PM�4✓ Sot S �f/SF/.0• I. PERMITISSUANCE ❑ ❑ 0
LICENSEDCONTRACTOR'S DEC RATION.f ey/L�iI APPU&NCFSRESIDCNTIAL - OB Dla� %)N
veiths etlom mthatiam Bcen3ofthe ur nr slonaof Chapler9 v,r dmy ] rNPR `e '_^_nu. .I"10.^I�c5P
Ingwith Scion for."DlWalan3ofthe Buslnessand Pro/salonaCode,and mY PANELS I VL Ia�-,'l Ca �W.1 �1
license is in full form and effect.
Lice siCiaes ��{7'�j(��p4r I'-•-
Date Comranor TU1100BAMPS q L -pL
�� �� ARCHITE UECLARATION I OVER 1��� - � '� &,y SQ. AR $1`Q FT'
Rob 7O 1 understand my plane shall be used a public rccorda. -,
U Licensed Predeaimnai .I.' SIGNS ELECTRICAL P ^ -
OWNER-BUILDER DECLARATION I SPECIALCIRCUIT/MISC X TER
I� IhembyafRrentha/Iamexempt fromthe Contractoes License Law for the \e�
X9 C� followingreaon.(Section 7(til Business and Professions Code:Any city or l' �P,METEKORPOLEINST. hA lf
F7tpp't�i cauntywhich m;imsa permit to construct,alter,Improve,demolish,orrepalr - - - � '
gO�j� anystrulurc prlormlls 1.wtan<e,alaosequlmatheappllantfurauch perMtto )EWER DEVICES
L5 fCCCdd., file a slg�cd statement that he Is licensed pursuant to the proWelom of the
Contractors License Law(Chapter 9(commeneing with Section 7000)of Div- SWIMMING ING POOL ELECIRIG
'30J sion3ofthe Business and Prefeedoes Code)orthat he is exempt therefromav^ �VAf�LUATION
&¢..••53333 the bass for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWITCHFS$FIXTURFS - QVo (
applicant fora permit subjects the applicant to a civil penalty of not more than
oBve hundred doilan(5500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRICTION
�1,as owner of the property,or my employees with wages as their se'^ _
r„7.t c pens n,
atlo will clothe work andthe structure b not intended or offered for]- ,
gg O sale(Sec. pply to alnowandf propeors Code:The orimp ROta hereonL
donno[auch ork ownerdtheaugyiso nemplyces,provided thereon,and OCC.GROUI' RES.UNITS
whodoeesuch am not msededorough hisownemp,1how,erthe uildl
improvementbwld intendneyearferedfoleio.t[h er.g iidertiding or TOTAL:
improvement proving old within he did et Wild frpurose of sal t,. 1
u ej L as wrier of t e property,a budd or Improve thig with Itm w `QT'y. ' MITI {1MBiNG PERMIT ', .,' FEE. FLOOD ZONE nrN
LJ 1,act owner of the property,am exclusively cse.ed Pimwith of Cone; PFRMIR ISSdANCE
rontraRon to ronstrul the project(Sec.9044 Bualnea and l'ro/mlons d
The Contnctors License Law does not apply to an owner of property w ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves therron, and who contracts for inch piapcb with a I ' t'i )t,' .,,FEE'SUMMARYI
�lTaloinexlcent under Sec to the G011trietOre License Gw. I BACKFIAWrROTFCT.DE'VICE
am exempt under See B&P C for this rearm - - /UTStnF'1'I'FS I
DRAINS FLOOR ROOF,ARIA,COND. I SANITARY Y N
Owner Date _ _ RECEIPT X WORKMAN I have ANSATION DECLARATION pl%'NRCS PER iRM SCHOOL TAX Y N
❑f hereby affirm That I have•certificate of consent to eel(-Inwre,or a I I REC®'1'X
certificate of Workere'Compereutten leamnote ors certified ropythereoflSee. GAS EA.SY5IEM-I INCAOUTLETS PARK FEE Y N
3800"Lab C) I 1 RECEIPT 0
PolicyM 7��y � X90 _ GAS EA.SYSTEM-OVER BUI LDING DIVI SI ON IT CS t
• Co ne ny�[ LL. ,7j m. �1'Xfi_f-ci NY/ -_ .
Goa Cert ,T- copy is heeby mbhed. CREASE/INDUSCRL WASTE INTERCEPTOR
PLANCHECK FEE
LY-J,Certified ropy Is filed with the city inspection division.
CERTIFICATE OF E%EM PTION FROM WORKERS' I GREASETRAP PAID
COMPENSATION INSURANCE sEwER-SwNH,Mty-SrolrM pA.zooFr. - Date RCceiPIM
(1'Nsae lion need oat bs completed if the permit b forone hundred dollar
($1011)orinss) - WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of thework fmrwhich this permit Is issued,
' I shall not employ any person in any runner so a to become subject to the WATER SYSTEM(TRFA'RNG .- I PAID
Workers Compematxm Laws of Califomla.Date
Z'Z Applicant NEW RESIDENTIAL rLMB.__SQIT. Date Receipt#'
O NOTICE TO APPLICANT.IL after making this Certificate,of Exemption,you TOTAL:
should become subject to the Workers'Compensation peavislons of the Labor
CC N Code,you most forthwith comply with such Provisions or this permitshallbel BUILDING FEE
LU > deemed mvaknd: SEISMIC FEE
W — CONSTRUCTION he.In. LENDING AGENCY
C. 0 lherebya(llrtnthat there ba construction lending agency for the perform) TOTAL: ELECTRIC FEE
�.Z once afthe work for which thb V 3097
permit LSSUCd(Sec. ,CIv.CJ '-
, - -- ----- (PLUMBING FEE
L) O lenders Name
F LeMer's Aadmss. (QTY. MECHANICAL PERMIT FEE I MECHANICAL FEE
O W " Icedlfythatl have madlhbappltatlmnatsd statethattheabove informatlon� rmMrnsqunxcE IFEESPAID:
C Is comeci,1agree to comply with all cityand county ordinances and statelaays
relating to building construction,and hemby authorize e,presentstives of thb
T In ALTQRORADDTO MPCH.
chyme give to the,Indecentlyo.d property the City purposes. - -_ ate ReCeiptk
(We) give to save,Indecently mg.andkeepes whihthe Cityy a ameac AIR HANDLING UNIT U010,000 CPM)
V
against liabilities,pdgments,roms and expenses which may In anyway accrue) SUBTOTAL:
ag,iWd,ud City In sequence of the granting of this Permit. AIR 14ANDUNG UNIT 0V M I%0WCFM) CONSTRUCTION TAX
_ t9�i CONSTRUCTION TAX PAID:
tore of AppllaN/Cronin or Da E%1fAU5FHOOD(W/DIC'D
HA2AADOUS MATERIALS DISCLOSURE HEATING UMT(T0100,000 BTU)
Will the appBant or future building occupant store or handle hazardous Date ReCeiptk
materlalas deflned by the Cupertino Municipal Code,Chapter 912,and the I HEATINGUMT(OVER 100,000 BT AL:
Health and Safety Code Section 25532W2 ����4 liL
❑Yes '-M No I VENTILATION FAN(SINGLE RESID) ISS'A' DATE
Will the appliamW future building occupant use equipment or devices (
which emit hazardous air ronta mlmnts as deli ned by the Bay Area Air EoILFR-COMP C311F OR 10Q,000 BTU) �y �r11� •
Quality Management District? N
4havc read the hazardous materials requlresrentsunderChapte r6.95of I BOTLLR.COMP(OVER 100,000 BTU)
71s
the CAI forma Health&Safety Code,Sections 25505,25533 and 25534. I I sri� Q
undcntsmd that ifthe building does not currently haveatenanL that it is my NEW RESIDENTIAL MEIN. SQ.FT. y7
ro ponslbil ty to notify the occupant of the requirements which most bs met
Prior to Ixuance of.Certificate of 02cupency. _
Owneror.uthorlmd,gort - Date
TOTAL:
OFFICE COPY