21051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Butldln Proet Identification PERMIT NO. 1
Building Address: . 2105.1
bl
sera _ One: -
C_gW6-EV, 2,rj'La.['�'3 E, - CITYOFCUPERTIN6BUILDING DIVISION p A
Contrax e.Ni11e: LIc.N.: APPLICATION /PERMIT
BUILDINGMDCTRICAL-PLUMBINGMF LAICAL CATIGORY CONTROL N
Architect/Engineer. Lle.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE - a _1:1 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby affirmthat l am licensed under prmWm.of Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DFSCRIrrION
Ingwlth Section 7000)of Divlsim3 ofthe Business and ProfeslonsCode,and my
limens Isles force and effect. PANS
License Clam LIc.N
Date Contractor —UP TO 2D0AMpq
ARCHITECPS DECLARATION 201-1000AMPS
02 I understand my plans shall be used as public recons OVER IOW AMI9 SQ.FT.FLOOR AREA S/SQ.Fi.
�qq�u, CO
S I(d Licensed Professional SICNSELFGTRICAL
I; OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MIEG
ZE, � Iherebyaffirm that lamexempt fromthe Contractor's License Uwforthe
oo following reason.(Section 7031.5,Business and Professions Code:Any city or
,02E TEMP.MEM OR POLE INST.
muntywhkArtgrtoi prMct alsomrquiiltheapU=tfmnWh,orrepalr
systmcture statements Wuanegalw requ pursuant
to the rovidopeimitto
e POWER DEVICES
'file'A signed statement he b r I(cod pursuant it the tion 70os of the
[$R?3w Contenor'slleese.d P fpler9Ccom)orthathet Setinn7W0)of Divi- SWIMMING POOL ELECTRIC VALUATION
"'SOS sbn3o(the BusNesand Pra(eslons Code)orthat he lsexempt lherefromand
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE•ISSWITCHFSFIXfURES d�_
applicant for.permit subjects the applicant to a civil penalty of eat n me than
Ove I�undred dollars%500). p
'9..' LJ 10 is owner or the property,or my employee with wages as t e87e STORIES TYPECONSTRUCTION
rompensatlon,wWdothe work and thettructureis not intended or ocmd'fo `' '-✓ d J
sale(Sec.7094,Bualness and Profeslos Code:The Contractors Llc w
does not apply sou owner of property who builds or improves the and
$ e - OCC.GROUP RES.UNITS
whodoessuchworkhlmsegothrough Mso wnempI ses,providedthatsucA
improvements are not Intended moffered forsale.If,howeWr,ihe bull d TOTAL:
improvement is sold within one yearofcampI tory theowner-budderwB
t)L,Jhwden of proving that he did not build or improve for pu/pmeor sale.). Q RMIT FEE FLOOD ZONE APN
r ntoa,as owner of the properly,am exclusively contracting with license PERMIT ISSUANCE
mrators to construct the project(Sec.7044,Bonds.and Professions Cade:
The Contractor's License Taw dos not apply to an owner of property who
bines or Improved thereon,and who contracts for such ptokcts with a ALTER-DRAIN h VENT-WATERS ..
Ttor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
am exempt under Sec: B k P C for this reasons RACK FLAW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY. Y_ N_
Owner Date - RF.Cm'f N
WORKMAN COMPENSATION DECLARATION
❑T hereby affirm that I have a cortifiate of consent m self4mum,ora P%NRES PER TRAP SCHOOL TAX Y_ N_
mAifimte of Workers'Compesatimisuranm ma mAlfW cDpylhereof(Ser. RECEIPT M
3800,lab C.) - GAS F.A.SY51EM.1 INCA OUTLETS PARKFFE 'Y N
policy N RECEIVE N
Com any - GAS EA.SYSTEM-OVER4 MAI BUILDING DI VISION FC CS
CetlRea copy is furnished.
CenlCREASE/INDUMn WASTE INTERCEPTOR PLANCHECKFEE
fied copy is filedfiled wwithh nicity Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
I
COMPENSATON INSURANCE
Ohiseetlon need no PENS lN Iu Permit istorose hundre dollen SEWER-SANITARY-STORM EA 200FT. Date Rece3 tg
(SIM)or less.) ' WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certlfythat in the performance of thewok lorwhirh this permit G Issued,
I shall not employ any person in any manner as as m become subject to the WATER SYSTEM/TREATING
Compensation Laws of California.Date PAID
-
0
Z Applicant ' - NEW RESIDENTIAL PLMB. SQ.Pf. Date Revel tN
O NOTICE TO APPLICANT.If,sitar me king t his Certificate of Exemption,you
F should become subject to the Workers Compensation provisions of the Labor TOTAL:
V1 Code,you most forthwith comply with such provisions orthis permitshall beOB
W > deemed revoked. D _ X
ILCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a commucton lending agency for the perform ELECTRIC FEE
ZanmoftheworkforwhlchthisperMtislseued(Fwc.3097,CIv.C.I TOTAL:
V Q Landers Name PLUMBINGFEE
LL H Lend.,.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I orilythat l have readthisappliahat tionand statettheabovelnformation PEES PAID:
1 isommt.l agreeto complywith all cityand county ordinances and tale laws PERMIT ISSUANCE,
relating to building construction,and hereby authorize representatives of this
N
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date RCCCt f#.
_ (We)a to save,IndemNfy an d keep harmine the City of Cupertino -
agairet b111Ros,�udgmenb, expense which nuy In anywayacome AIR HANDLING UNIT Cf0l0,OW CFM) SUBTOTAL:
,agar dCity In mnseque he grant Ng dthls pe B. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
ighato IApplicant'Co
n razor to EXHAUST HOOD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERI SD CLOSURE
theapPBmnt or fumrebudding damorhandlehazaeous HEATING UNIT(TO 100,000 BTU) Date Rmci t#
ma alae de0sd by the Cupertino Municipal Code,-..-,.-.
Heilth and 9.1$and the
Safety Code Section 25532(.)7HEATING UNIT 1W00 BTTOTAL:
I—I YrsP No
III the app0antocore building as occupant Bay Atardeviaa VENTILATION FAN(SINGLE RES[D) rOCIa A1lN'F DA'I'S
whichemithazanlnt air contaminants as defined by the Bay Area AU dCC""'"'
Qui iity Masgement Dle No BOILER-COMP(3fN OR 100.00)ETU) -
i,aYed "° SER l.� 1990
vc read Healthhe
outs ode,SetioW25505, 5533 and 25534.
of BOILER-COMP BTU)
the Gltandffomi Health building
Code, otcurentlyh have
at and25539.I
-� understand that if the building does not currently have atenanL that ltismy NEW RESIDENTIAL MECH. SQ.IT
resposlb0ity,to notify the occupant of the requirements which mustbemrt Lill Pf Fll�':!�lQp
pdm to Lsuance of a Cedifi.N of Occupancy.
Owner or authorimd agent Data - ISSUED BY:
FT
TOTAL:
OFFICE COPY