21431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.
Building Address:
209 1��oa��.ie// lir 2 413
oar aams: one:
APPLICATION SUI19rrrAr=a-1r,aV50 11 1- CITY OF CUPERTINO6BUILDINGDIVISION
c° °''Name: u9. APPLICATION 1 PERMIT 8 b�
V(J MSO//I` D BLULDING-ELECTMCALPLUMBINGMECHANICAL CATEGORY CONTROL#
Arthlted/Engineer. Lk,Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
?,�yZ PFRMITISSUANCEEl ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am lkensed under provlalons o/Chapter 9(mmmenc APPEANCESRF9DENTIAL JOB DESCRIPTION
Ingwlih SeMon7000)of Dlvision3ofthe BuslnessandFro/esslondCode,and my
Iimnsekln(sal ice de!(ect, 3pQ ^lt PANELS '
LlcenseC Lk.#
Date Gel �n
ARCHITECT'S DECLARATION 201-1000 AMTS
NZ I understand my plans shall be used as public records. OVERIOOOAMPSQ.F��RARFA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL R
6�° OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
OO a Iherebyamn.(Saatlamnemptfromthe ContnctoreCode:Lw(m the
Z r� (olloywhichmqui saperudttomBusinesscandy,Professionsemle knytltyor TEMP.METERORPOLEINST.
P� [3r7 cwntywhlch requlresa permlttomrutruc[,alter,impmve,demoWh,arrepair i
any structure prior to lb Issuance,also requires the applicant for such permit to O POWER DEVICES /I fib a signstatemented tement that he Is Licensed pb pm.., the powEdons of the
�µ�• Contractor's License Law(Chapler9(mmmendngwith Section 7000)ofDlvl-
OS M.n3o(the Budneuud Pro(mbnsCode)orthathelsexemptthemfromand SWIMMING FOOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any do
,gyp/��
applicant fora permit subjects the applicant to a civil penalty of net more than OU'TLETS-SWITCHES (/
live 1,as
dollars%500). NEW RESIDENTIAL FLECTR SQ,FI.. STORtpS TYPECONSTRUCTION
Xi ❑e ea owmr o!the property,or my employers with wages r there dole
C a
compensation,7lon,will do the Business and Prod the fessions
ode:Th set intended or offered Law
'S
sale(not apply
to a Business macer
f property
who
builds:The Contractees llceme law
�$ does not apply loan imserofpropghhisonmor Improves[hereoryand OCC.GROUP RES UNITS
who does such work himae de lhrwghhbownempl howe er theb that goy
improvementsarecad thindneyearfcodaraffeforeak.If,hmvev-b flder iiln ve TOTAL:
Improvement Issdd within one yearo(compldbry the owner-W Oderwlll have
tllLkurden of Proving that he did not build or Improve for purpose of sale.). QTY, PLUMBINGPERMIT FEE FLOOD LANE APN
LJ I,as owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
mntractore to censtud the project(Seo 7061,Business and Professions Code:
The Contradofa License Taw dm net apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
Wilda or Improveand thereon, d who contracts for such p(ojects with a
-pj(actw(a)licensed pursuant b the Contractor's Lkame Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec B k P C for this mown
Owner OUTSI UP FEES
DRNNS.FLOOR RODF,AREA,COND. SANITARY Y N—
Dm RFGEIT N
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCIiUUL TAX Y— N_
QI hereby affirm that T have o lmu rate of consent to opy them. ora - RECEIPT N
certlflnteo(Werken'C`emQpematl.nlnsuranm ora certl(hd copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380011.10C.) /`�j_l tee/
Polity n o /s em-� ..�. DING Df N
Com a (Ijjryd�I. aj py— GAS FA.SYSTEM-0VER6(EA) BUILDINGDIVISIONFEES
Certified copy IsTiledwththe city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�Certaied copy V filed with the sty Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA 200FT Date Recef t#
(Thos section need not W complded I(Ihe pemdt V(Drew hundred dollars
(E100)orfesss3 WATER HFATERW/VENT/ELECTR ENERGY FEE Y N
' Icertifythat In the pedornunce.(less work(.rwNch this permitb6ucd, —
I shall not employ any person In any manner w co
as to become subject to the W,A,PER SYSTEM/TRFATING
Workma Cmr Pensatlonlaws.ICaflfomia.Data PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei t#
Z O N'OTICETO APPLICANT:If,after making this CerH(lote o(Ezemplon,you
should become subject to the Workers'Compensation provl'terelhe Yu TOTAL:
fn Code,you mist forthwith comply with doth provisions h permit shall be rr
] deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
ll Ihereby affirm that there is a construction lending agency for the perform~ TOTAL: ELECTRIC FEE
7O ante ofthework for which this permit is Wued(Sec.3097,C1v.C.) ELECTRIC EEE
V Lenders Name
LL E- T<eder:Addreaa MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertltythati have readthtaepplirotbnand tlarelhat theabneebfomution -
1 Iacorred.l agree tocomply with all city and countyordinancesmd nate laws PERMIT ISSUANCE FEES PAID:
} W relating lobulldingrorectuction,and herebyauthorimnepresenmives.(this
Z etylo enterupon the above-mentioned pmperty for inspection purposes. ALTER OR ADD TO MECH. Dale Recei t#
_ (We)agree to save,indemnify an d heartless haress the City of Cupertino P
agaWthabNtlea pu gments,codteandexpenseswhl muy lnanywayaceme AIRHANDLINGUNIT(rO10,OWCFM) SUBTOTAL'
egacotsaid ilyl con equen o hegranting •permit '
I AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
S18. o(Appbrant/Ca on Pat. EXHAUST HOOD(W/DLXCn CONSTRUCTION TAX PAID:
HAZAR O MATERIALS DISCLOSURE
WllltheappficanI or future building occupant store or handle hazardous HEATING UNIT CM 100,I100BTU) Date RLreI t#
material as defined by the Cupertino Munidpal Code,Chaptar 9.12,and the
I Icalth and SafetyCode Section 755Mall HEATING UNIT(OVER Ile,"BTU) TOTA
❑ Yes No
Will theapplimnt or torebuilding°cupanlusesquipmentmdevlm VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hasardoes air cmumdronbaa defined by the Bay Area Air pp�� pp e
Quality Management Distrid? BOILER-COMP OHPOR 1(10,000 BTU) g' A
�YI 4 No
aread thehazar Dud matcrlab requlrcmcnb under Chapter&95 of BOILER-COMP(OVQt 100,000BN) 16 1992
T.
�pC%ob
—'hASafetyCode,Sectimot25505,25533and25534. 1 OCTdthaHfIhe WlldmSdcea nolcorrentlyhaveatenart,thatitiemy NEW RESIDEN77AL MECH. SQ.FF k77lJoy t.cadify the onvpant.(the requirements which It be rtr•t
prior to issuance of a Certificate of Occupancy. - CUY U1 QUra iiill1
Owner or authorised agent -Date ISSUED BY:
TOTAL:
OFFICE COPY