21361 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Huildint Pm'ect Idemlflcation building Address. PERMIT NO.
21361
one. A
I —�Q6 CITY OF CUPERTINO-BUILDING DIVISION 117-
Ors Na
Cum' me: - : l
:Tic. ' APPLICATION /,PERMIT 1I __223
�' prtMtect/Engineer.
Llc.Na BUILDINGELFCTRICAI.PLUMBINGMECHAMCAL ` CATEGORY CONTROL
; ;BUILDING PERMIT INF
nnare,.:
�_3 ;QTY r' ELECTRIC PERMIT FEC fir' i'-
� 7. lira
PERMIT ISSUANCE ❑ ❑ ❑
LIC ENS EDCONTR under ,DEC RATION
I M1ercbyion700)of affirm that I amlicensedfth. erprovWonsof Chaper9(cvmmenc APPLIANCESRESIDENTIAL
tog t...ISatanin.afDlvWon3 afthe Buynessand Prolesslons Code,and my � JOB DESCRIPTION
license la I.li fuse force and cited. rP.O� pnNp�c wlV1�n� w n
LicenseALss —3L LIc.M
Date Contactor L> LMTO200AbVq - '
ARCHITECTS DECLARATION ZO11000AMPS -
ONZ ]understand my plamshall be used upublicrecords. OVER 1000 AMPS - , SQ.Fr.FLOOR AREA ,y/SQ,FT.
Fi z Licensed Pro(enlanal _ SIGNS ELEC CAL } -
Q Id OWNER-BUILDER DECLARATION
l, ,�g Ihereby affirm thatIamexemptlromtheContractor'sLlcemeLawforthe SPECIAL fIRCU1T/
O 2 Y a following reason.G tion 7031.5,Business and Pnefookma Cade:Any city or
p4 .a county which requlresa permit to construct,alter,Improve,aem.11sh,orrepalr P.M POLE INST. ,
,§ .� anystruRurepkrto Its lwance,also requlrestheappucent forsuch permit to s
G file a signed statement that he 6licensed pursuant to the provisions of the DEVI
Contractor's ru C.ntraor'a Liceme Law(Chapter 9(commencing with Section 9000)of Dlvl- b a
p�05 yon 3 of the Business and Profemlors Cede).,that he Is exempt therefromand NC POO E- C
the boals for the alleged exemption. Any violation of Section 7MIZ by any N VALUATION
O� applicant fora permit Subjects the applicant to a civil penalty of not more than O SWITCHESSEXTURES
five hundred dollars($500).
MI,as owner oftheproperty,ormyemployees with wages astheira.le NEWRFSIDENTIALELECTR 1✓I FI. STORIES. TATE CONSTRUCTION
�7 comNnsation,Mlidothework,andNestrucmrels noHntended or offered for
O sale(Sec.9044,Business Professions Code:The Contractors License Law
does not apply to an owner of property who builds or Improves thereon,and
who does such work hlnselforthrough his own employees,provided that such OCC.GROUP RES UNITS
Improvements are not Intended proffered for sale.If,however,the building or -
improvement Is sold within one year ofcompletiorytheowner-builderwill have TOTAL:
te rdenof proving that he a id nor build or improve for purpose of sale.). QTY. '1,','PLUMBNGPERMIT �-
f as owner of the property,am exclusively contracting with licensed 'FEE_ FLOODZONE APN
contractors to commad the project(See,7044,Business and Professlons Code: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who -
buude or Improve.)thereon, and who contracts for such ptu)ects with a ALTER-DRAIN&VENT-WATER(EA) '
c actor(a)licensed Pursuant to the Contractors License Law. '` / '` ,'FEE,SUMMARY
LJ I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE t 1' '!
• Owner Date DRAINS FLOOR ROOF,AREA,GOND. - SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT M
Imo,I hereby affirm that I have a redWate of consent to self-Insure,or a FIXTURES'PER TRAP SCHOOL TAX Y N
<ekifa, of Wotken'Compersation Luumnre ora emitted copythemof(Sec. : RECEB'fN
Polis Lab CJ GAS EA.SYSTEM-1 INC.40UTLETS PARR ppR Y N
Policy N RECEIPT N
Com any CAS EA.SYSfE.1-0VERd(FA) -
Cemi(ledcopyishereyfurnished. BUILDINGDIVISION PEES
Germed copy is filed with the city Wpectlon division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'„ GREASETRAP PAID
COMPENSATION INSURANCE
Rhbsectlon need not becompletea lithe permit isf.ronehundred dollars SEWER-SANITARY-STORM EA,20OFT. Date Recei t#
($100)orlexx) -
I certify that in the performance of the work for which this permit is issued, I WATER BEATER W/VENT/ELECTR �ENERGYFEE .Y - N
I shall not employ any person in any manner so as to berorre subject to the
O Workcm'CompereatoAUwsof Callfomia.Date WATER SYSTEM/TREATING PAID
Applicant
Z Q NOTICE TO APPLICANT:R after making ehCoCertRlote of Exemption,you NEW RESIDENTIAL PLMIL_SQ.E I. Date Recei I#
W
should become sub=,,otheW.rk"a COmpematlon provisions of the Labor
/ COde,youmust(oth comply withsuch provisions or this permit shall be TOTAL:
W > deemed revoked. BUILDING
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I herebyaffirmthat them is a construction lending agency for the perform,
ance of the work for which this permit is lssued(Sec.3097,Civ:C.) 'TOTAL: 1l1 M ELECTRIC FEE
V 0 I.oder'.Name —1 eW PLUMBING FEE
F Lender'.Address QTY. `r MECHANICAL,PERMIT: " FEE;,
0 W Iemlfythatl have r.adthisapplkatlonand statetha<theabovelnformatlon MECHANICAL FEE
fl b,torted.Iagreeto comply with all ety and co.myordimmes and teat.laws PFRIrr ISSUANCE - TEES-PAI D-
in relating to building comlruti.n,and hereby authodre representatives of this
— Z city to enter upon the ab.vcmcmionea property for inspection purposes. ALTERORADDTOMECH.' '
J — (Wo)agree to cave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,c.ta and expenses which may in anywayaceno, AIR HANDLING UNIT ITO IQODO CFM)
agAnauCity In consequence of the granting of this permit SUBTOTAL:
T Z" trrlanolhp � 1 AIRHANDUNG UNIT(OVER IQWOCFM) CONSTRUCTION TAX
Sigmture.f Applant/Conggq Date
HAZARDOUS MMTERIALSOSURE - EXHAUST HOOD(w/DIIC77 CONSTRUCTION TAX PAID: `
Will the applicant or future building occupant store or handle hatiNous HEATING UMT(TO 100,000 BTU)
murrulm defined by the Cupertino Municipal Code,Chapter 9.12 and the Date Recel t#
Flmlthaad SafctyC hie 25532(.))7 HEATING UNIT(OVER 100,000 BTU) ' (yI^T
Yea No TOTAL: 4 W'
Wi writ appllant or mrebuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) L�J(k[x]EE DATE
whichemit hazardous air contaminants as defined by the Bay Area Air - `� ((j�/
Quality Ma,ugcrrent 1st d7 MOILER-COMP(3MP OR 100,0(10 BTU)
4Yes Q�_Q�1No
havcreadlheb zaldLVsmaterla rcquImmentsunderChapter6.95of BOILER-COMp(OVER 100,O)BBTU) 1990
the GllfomW Health&Safety Code,Sedlons 25505,25533 and 75534.1
understand that lfthebudding does not currently have.tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
1espomtb0ity to notify the occupant of the required ments which must be ana.� s,
Prior toissuance
Lof a Certificate OfOmepa ncy. City,Of airomr* -
owner.,authorlud agent ' M1�Date
��_ .• - - � �M.-s
TOTAL: I ISSUED BY:
OFFICE COPY