22813 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN O_ NLY
BOIIdInR Project ldentiflcatlun '-" `• PIR,WT N-/O�)'/�) q
IBuilding Address:`y4 /,n)- J��j//(J_ 2 2 813
uw�a aY9. q, " ' /�6w -'--40lr L41ve N'l'Li(J�IIUN SUtlMII'1AI.DAtn
mmmCCCI� Pnd k: 2
�... �< ������/2� �.s1•�CIT�OF CUPERTTN0.6UILDING DIVISION /D
Cos scion ame: p i=.Ne: APPLICATION I PERMIT ( T
d U� {: n� BUILDI NGELECTRICALPLUMBING-MECI IANICAL CATEGORY CONIROL��D/
Architect/Ggin-r.' Lle.No:
BUILDING �RMITINFO't
.�� QTY ,I, ,ELECCIUC PERMIT,' ,�1 4FEE' �t w I�1 11,7mn mLl.it
' Addrc,c `�� f7i0A�GF(Fr T7 � �[- I PERA9TISSUANCE � o �
LICENSED CONTRACTOR'S DF.CLARA�ION I APPUANCESRESIDENTIAL JOB DEtiRA'RON
T ith St affkmthatf lu Bcen3edunder oessannsal Chapter9 de,and my
" Ingwlth5edlon7000)ofDlvislon3oftheBminneandProfesslomCode,andmy T `
honnsc le In full( and effect. q_-o4?Z PANELS C-0
���� �a-t `Ot
Lkx,.Clare Lk.N ) '[Q (1�
Cunt OVE�OOAM . , � � IAA
ARCHITECFSDECLARATION I OVER 1000 AM q �`�'h7'E7'ODRFA �f/=Q'PF
p�L�I++wmOus�p Iundenland my playa slall be used as public molds. s�.. 1�'I ✓� � N�
Licensed Professional SIGNSEL CAL r 7 N `
<<�6 OWNBA-BUILDER DECLARATION SI'ECIA RCUIT _ pp.�(
' N ■
s X - I hereby affirmthat l am exempt from the Contractor's Limner law for the f V ��•'
XO^ following maean.(Setion 7031.5,Business and Pecifcssions Code:Any city or gyp, ETIR OR
countywhich requ4es a permit reconstruct,alter,improve,demolbh,errepair I -
�L anyst-durepdm to its Issuance also exqulrestheapplicant for permit to DEVICES A
a Bln a signed katemenl that he b licensed pursuant to the pmvbimer of the '
O Contmdoes Llceme Lw(Clupcer9(mmmencingwith Sealon7000)of Divi- NG POOL EC C VALUA77L� 1�
sion3 of the Busm=ssand Profeeaiov Code)orthat he b exemptthercfromand (J(/
Gthe basis for the alleged exemption. Any Nolatlon of Section 7011.5 by any I OUTL TSSWfTC FIXTURES/
OS.] applicant fora permit subjedsshe applicant tea=)vil penalty of n-more than {
$
five hundred dollars($500). NEW DFIMAL ELF(' SQ.FE. S[D FS ' TYPECONSIRIICTION
❑1,as owner of the property,or my employees with wages as their m,, '
s,2Q compensation,willdothework,andthestrudure bectintended or offered for
�7 ❑ sak(Sec.7044,Bu an,owandf Property Cade:The Contranora LlonnuU
$ doesnotapplyto an owmr o(property who Wilds arimproveethereon,and 1 OCC.CRON' EIS.UNITS
who doessuchworkhimeelf orthreughbisownemployeea,provided that.. -
improvements arc not intended proffered foreals.IL howeeer thebullding or TOTAL
I-provemant b sold within oneycarofcompldioM the owner-bullderwill'
t1lspnrdea oiprovingthath=did nutbuildmimproveforpurposec laxle). IQTY. ,�!JpLUMBING�PERMIT; FEE FLOOD TONE APN
Lj L as owner of be property,am exclusively contracting with licensed I PERMIT ISSUANCE
contraden to construct the project(Sec.7044,Business and Profession,Code:
The Contractor's Licerue Iaw don not apply to an owner of property ALTER-DRAIN k VENT-WATER(RA)
Wild,or imp.thereon,and who contract, for such p,jnds with s� - � �+, .'� ' � { 11 FEE'SUMMARY (, t
cgRt(actor(s)licensed pursuant to the Contractor's License Law. ` BACK FLOW PROTFGT.DEVICE
I�1 am exempt under Sec. B dr P C for this reason jj,D-slnla'1'us
' DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owns' rnate RFGFR'T N
I WORKMAN COMPENSATION EMRATION FIXTURFS-PER TRAP 1SCHOOL TAX Y N
/INI hereby affirm that I have a-rtiFlrate of consent to self-Insure,or a I RECEIPT N
N(IcateofWOrkns'Compereabui Lauren-ma certified-pythereof(See- GAS F.A.SY5EEM-1 INCAOUTLETS PARK FEE Y N_ - —
38WLabC.) / RECEIPT#
lvicyN GA&FA.sysTEM-OVER 4(FA) BUILDING 01 VISION FI:ES I
- Cnm an� arF L Mfi INS.
ffCanl,ed copy 6 hereby furnished. I CREASE/INDUSTRL wwsrE lNreRClaroR PLANCHECKFft
®CerHned copy b filed with the city Inspection diviann.
GREASE TRAP —3 pp `yI J a \
CERTIFICATE OF EXEMPTION FROM WORKERS' PAID U +'`f- B' S a
COMPENSATION INSURANCE SEWFILSANTTARY-STORM EA."FT. I Date Receipt713�
(rhisaedion need not be completed If the permit b for one hundred dollars
%IW)mlcss.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y^ N_
I certifythat in the pa forman-of the work forwhich this permit Is Issued,I
' 1 shall not employ any person in any manner so as to became wbjM to the I WATER SYSTEM/TREATING I PAID
.WoskOix ComPenammi la—M Glifmnia.130-
0 Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date ReceinW
Z 0 NOTICE TO APPLICANT:E,after making this Certlfless of Exemption,you I TOTAIt.
should becomesubject to the Wmkere Compensation Pme iom-(the Labor .�p� I
F- 0 Cade,you at fart hwsth com previsions ply with such pvisions or this permit shall W BUILDING IT.E_ �
CC
CC 5 deemed revoked. 1 SEISMIC FEE - a
CONSTRUCTION LENDING AGENCY
d I hembyafOrmthat there b a-mtrudion lendingagency for the perform-I TOTAL: ILLECTRICFEE
b
Z- anon of the work for which this permit Issued(Sec.3D97,Clv,C.) PLUMBING FEE
U O Landers Name I'QT'y ;I :"MECHANICAUPER�lFr I
LL H' Lender,Adders- ,. "tt=..'_4. E MECHANICAL F'BE
O w Icertlf ythatl have mad thbappBott onand date that theabove Information I f \Y 777��� �pgp�pA bt
Is corned.I agree to complywhb all city and county ordleancesand Rate larva PERMIT ISSUANCE
} 1 relating to buildingconswction,and hereby authorbeerepreadalativnofthis I \
(/) I ALTIRORADDTOMECH. Date Rec 'Aril
Z
city to the property(-Wpecil it purposes.
(We)agree to nave,indemnify an d keep harmlem the City Cupertino AIR FIANDLING UNIT(TO 10,000 Cr M)
agaWttiabllltlex,ryd nb,co,ln and expenses which nay In any wayaccrue I SUBTOTAL:
Sales'
City sequenceo he graml of this pertnR AIR RANI NG UNIT(OVER I0,000CFMl ' 1 CONSTRUCTION TAX
score of Appliant/Contractor ��Sl at EXHAUSCHOOD(W/DUCT) (CONSTRUCTION TAX PAID:'
HAZARDOUS MATERIALS UISCLOSUR£ }(GATING UNIT(TO 100,000 BTU)
Wdl the applcant orfuture building occupxntstom or handle hazardou, I Date RCCCIpt({ '
material as defined by the Cupertino Municipal Code,Chapter 9.l H,and the I �gyjQ1
I lea k h and Safety Code+—Section 25537(x)? HEATING UNST(OVER 100,tJ0D BTN ` TOTAL: l�}}rr�a
[3 Yea uNo I VEN'17LA EON PAN(SINGLE RESID) I ISSUANCEDATE
Will the applicant or future building Occupant use equipment or device
which emit hazardous air conmmisunts as defined by the Bay Area Air BOILER-COMP D HP OR 100,"BTU)
Quality Management District? • ',
❑ Yn ❑NO Q
(have read the), aRON materiab,mqulmrmrtsunderChapter6.95 of BO LER-COM (OV 7l1Q,D0047S ET
the California Health k Safety Code,Sections 25505, b 25533and25534. I I 1.I1 lass,!
understand that lfthaluiddingdoe,notcumcotlyhaveatena.L that It my NEW RESIDENTIAL MECFI. SQ.I7.
responsibility to notify the occupant of the mqusrenents which must be met I I �IJre Lit Y_/,
prior to Lssuance ofa CaHifi-teot Occupancy. ,_ s Clio
ets
re TOTAL:
iI (p
Owner or authored agent Date I (ISSUED B �
I
OFFICE COPY