21086 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProtect identification PERMIT NO.
Bpi Add o l U 21 D 86
ner. S fine: -
CITYOFCUPERTINO-BUILDINGDIVISION
C 'sAamy k.No: APPLICATION 1 PERMIT LL ^l
BUILDINGELICTRICA4PLUMBING-MMHAMCAL CATEGORY CONTROLN
rchbeci/E.0-- Llc.No: -
t ^� �" r r,• - . BUILDING PERMITiINFO..'_::,,''• -
-tS— ELECTRIC PERMIT. : FEE"` -
Addrevc PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmm APPLIANCE-RESIDENTIAL JOB DESCRunoN
ingwlth Sectidn7000)of Divlslon3ofthe Buslmnand Pmfese onsCode,and my ..._s
License la�iJanm B And
Llc N p 6 PANELS
Da(e C� CmAndrur
ARCHITECTS CLARATION 701-1000AMI5
O2 ]undenurd my plans ahaB be used as public recvnl.. OV ER 1000 AMTS SQ.FT.Fl.00R AREA B/SQ.FT.
O_
VIj Licensed Professional Professional SIGNS ELECTRICAL
Z"rOWNER-BUILDER DECLARATION
< $(+ECIALCBtCUIT/MISC
2 owing a(Rnntlutn. m,7ezem(Rfromthed Profnor's License law fm the
(elloywhichsequLmape Rt$Bms cn fid Pimp ovamhsh,ycityor ;MkTER ORPOLE IN57.i�. ��. VJ
puuntywhich requlrcsa permitromvwct,alter,Improve,demoLLsh,ornpair
anystm=mprlorteib Wuanckalsorequlmtheapphmntiwsuchpermittu DMS'
5 fde..igred mtement that he b licensed pursuant to the pecvblov of the
u,Ian
Contractors License Law(Chapter 9(commencing with Sachem 7000)of Divi- SWIMMING POOL ELF C VALUATION
O alon3 ofthe Business and ProfessionsCode)orthat he b exempt thenfromand {T'')ku�FF /� /�
'}n 5 the basis for<he alleged exemption. Any Violation of Section 7m15 by any OI1iLE135WIT• �=J�l�' s 0�
Applicant for a permit subjemtheappllcam toa civil penalty of not mon than
five hundred ddlan(5500). NEW R}yDENTIAL ELECTR—_SQFr STORIES TYPE CONSTRIJCIIDN
❑H,As owner of the property,or my employees with wages as their wk
.y mpensaHon,will do the work and the structure is not intended or offered for
..O
Is(See 70K Business sed Profeadev Code:The Contnciors Llave Law
$$ don not apply to an owner of property who Wilds or improvn thereon,and OCC.GROUP MUNITS
who does such work himself or through Na own employees,provided that such
Improvements an not intended proffered for file.If,however,the building m TOTAL:
Improvementtsmldwlthinoneyearofmmplelioglheowner-bu0derwlll have _ r
t rden of proving that he didnot Wild or Improve for purpose ofule.). QTY �'=•' ,PLUMBING.PERMIT > O'' FEE" FLOODZONE APN
U L as owner of the property,am eachuively contracting with licensed PERMIT DANCE I^
mnmctm to mnaWct the project(Sec 7064 BusWm and Profmlov Code: 4
The Cmiusam'a License Law does not apply to an owner of property who ALTER-DRAIN III VENT-WATER(EA)
builds ar Improves thereon, m and who mrdrafor such pRojecis with a FEE'$UMMARY,'t� a
my¢+ctm(Ullansed punuantrothe Contractor's License Law. BACK PLOW PROTECT.DEVICE °- `-.
LJ I am exempt under Sec R k P C for this reason
DRAINS FLDOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION PICTURES.MR � cz SCHOOL TAX RD N
❑1 hereby affirm that I have•caMficate of consent roself-Wsure,m a RECEBT I
A maifimteofWorke Compena HmlvunnMM.Mdifiedmpythemf(Sec. GAS EA SYSTEM-1 INCE OUTLETS PARKFEE Y N_
3500,lab C3 RECEIPT x
Policy N GAS FA.SYSTEM-OVER d(FA) BUILDING DIVISION FEES
Com any
�CertlllAd mpybhereby fumlahed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy Is filed with the city inspection dr"on.
CERTIFICATE OF F)cRAPTION FROM WORKERSGREASE TRAP PAID
COMPENSATION INSURANCEsEVER.SANITARY-sro1RM EA.z(wFT. Date Recei t#
Qhlssev ion need not be completed lfthe permit bfor one hundred dollars
(5100)m1m.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
' IcertBy thtt Wthe perlomunce of thewmk forwMrh tMs permltbbaed,
1 shall not employ any person In any manner m as to become subject to the WATERSYSTEM/TREATING PAID
Wmisari Compensation Iaws.f California.Date
Z Applicant NEW RESIDENTIAf.PLMB_SQ.FT. Date Remi t#
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
2 should become subject to the Workers'Compewtlon provblov of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthb permit shall be_ G (�
> deemed revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I so
Z Ihereby.ffirentlut then b a commudlon lending agency for the perform- TOTAL: CV ELECTRIC FEE
Ince of the work for which this permit is Issued 5ec.3097,Civ.C.)
O larders Name . PLUMBING FEE t
r Lender.Addres. QrY. ',MECHANICAL PERMIT.,- ••`FEE -' MECHANICAL FEE
U Icart"at 've read thbapplkatimand mtethattheabove Information FEES PAID:
W bcorres.H me to comply with all city and county ordinanmand state laws PERMIT ISSUANCE
1 relatingt ullding covtructim.nd herebyauthorlee repnsentativesof this
N cityto fir upon the above-mentioned property for Inspection purposes. ALTER OR ADD70 MFLH. Date RCCCI of
? )agree to uv,Indemnify and keep harmless the City of Cupertino
net bilities' gmenta,m .0 .dexpenanwhichrvyinanywayamue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL:
m In consequence of the granting of this permit. CONSTRUCTION TAX
1 / �v AIR HANDLING UNIT(OVER I0,0O)CFM)
IB of Appllont/Contractor Date EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT RTO 100,000 BTU)Will the appBant m future building occupant stare or handle hazardous Date Recel t11
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the
Health and Safety Code,SKtion 75531 WI HEATING UNIT(OVER t00,00D BPM TOTAL: .5
Ya a
ill the ippliantm tore Wlldingampantuse equipment or devlm VENTILATION FAN(SINGLE RESIW I$$ TE
which emit hazardous air contaminants as defined by the Bay Area Ab
Quality Management Dot 7 gDB FR-COMP DIE DA 100,IXp BTHn
❑Yea L ]�nfl
Iluv..UH the F s xdrSedj0M 25505,2SS3And2pter6.95 of BOILER-COMP(OVER 100,000 BT1n
the CaBfomb Health feydin Code,cutcum75505,ve.mznd75536.1
unci e t Ildiri oes nm currently haves tenant that It b my NEW RESIDENTIAL MECF{. SQFf.
na311By1 Ify theP panto(the requlrcmenn which rrwst be met •ry s�=j*
rx,mIuth Art Date TOTAL: ISSISED BY: �a✓O IV"h� -
OFFICE COPY