21922 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
eudaingD SC07- - 21922
rs ams one: A
CITY OF CUPERTINO-BUILDING DIVISION
cono-°r '• a p LIe.N. - APPLICATION /PERMIT
_ -LD BUILDINGELECTRICALPLUMBINGMECFIANICAL CATEGORY CO OLN
A Itect/Enginser. No:2 • L
' QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.: 2lie ❑
PERMIT ISSUANCE
affirm
that I DCONTe under DECns of Ch ON ,
IM1thSy . 70lhatlamsimsaftheBuir annsateWm,rodmand APPLIANCESRESIDENTIAL JOB DESCKIPI"N
If...1 in
forces Dlviect. (the9ualnmand PafeWonaCode,andm
license le in full farce end d(M. PANEIS
License Classla
Ln `^"7���, /1^• 1(
Dale Cle,0 r Va l/ . •-L V
ARCHITECT'S DECLARATION 701-1000 AMT'S
pQ+Mz I understand my plane shall be used as public rereads. OVERHIRAMPS SQ.FT.FLOOR AREA $/SQ.FT.
F Licensed Professional SIGNS ELECTRICAL 3 2 7
«<< OWNEReBUILDER DECLARATION /
7 tr,,� Iherebyaffrmthatiam exempt lamnhe Cgntncior'e License Law for the SPECIALCItCIDT/MISC
oo (gVowing reason.(Secilan 7RI1 S,Buviness and Pafessbne Cade:Any city or
O z"� TENP.MEITI(ORPOLEI Sf.
.� county which requlmapermit lomostvct,alteq impmve,demolbh,orrepalr
anyenructure print to Its issuance,also requires the.ppBaant for such permit to POWER DEVICES
�d
file a signed statement that he la licensed pursuant to the provfslom of the
3w Contractor'eLlcenselaw(Chapter9(cemrrcncingwithSectWn7000)olDivi- NG ELECI'RIC/� �D8'O
OJ don3ofthe Bualnessarad Pmf.xalmaCode)mthat he lsexempttheretromand
•7 the basis for the alleged exemption.Any violation of Section 70315 any y �- - -sf
< applicant fora permit subjects the applicant to a civil penalty clout more than OUTLETSSWITCHESFIXT(JRES
Ll five hundred doll..($500).
�a ❑I,as owaer of the property, NEWR D ACELECTIR 9Q,B1 I� STOW• TYPECONSTRUCTION
p perry,or racy employees with wages as their sole
<
sole
Praedthestvde:Th nmiatended License
re Ls. _
O sale not apply to an ow and f Property
rops ty Code:The Contractor's thceve laW
R dondesuch to an owaerofprough hiso nem arlmp Provided
rovidnwcx dthat and _.uch C.GROUI' RES.UNITS
EE Improvwhodoee .ts am khlmve dedorwghhbowne.Il,however,playem, theedthat gor
improvements are not Intended earofcourplroffered •a.,thecerbuilderwdl have TOTAL;
Improvement la Bold within gneycarofcompldbM ted ownerbullder will have
'o tlAjZurden of paving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
UL as,owner of the property,am esclwively contracting with licensed FLOOD ZONE APN
mmnctors to aoruwct the project(Sec.70K 1 PERMIT ISSUANCE .0 • .
The Contractors Llmnee Law does not appy to anwner of property o
builds or improves;thereon,and who contracts for such pW)ecta with a ALTM-DRAIN&VENT-WATER(EA) Vo
cga(Iutar(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L I am exempt under Sec. B&P C for this meson BACK FLOW PROTECT.DEVICEOUTSIDE FEES
DRAINS A,FLDOF,ROOF,ARECOND. SANITARY Y N_
Owner - Dn+ RECEIT0
WORKMAN COMPENSATION DECLARATIONFIXTURES.PER.IRAP L) SCHOOL TAX Y_ N_
❑I hereby affirm that I have•certificate of consent to sail-Insure,ora .�. V RECEIPT M
(� cerltlate ofWorkeii ComperwtlonlvuranmaranniPled mpytheaof(Sec. GAS B.A.SYSTEM.1 INCA OUTLETS FEE Y N
3800,Iain C.) RFLF9TN
Polley p GAS F.A.SYSTEM-OVER 4(EA)
Com any BUILDING DI VISION FEES
'
�Cerltled copy is hereby to mished. GREASE/IE1DUSfRL WASTE INTERCEPTOR CHECK FEE
Certified copy b tiled with the city inspection division. 2 2 '
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP $ P D C+'
COMPENSATION INSURANCE $EWER-SANITARY-STORM EA.700FT. Date RBOCI t#
([his seelan need oat be completedIt the permit b faane hundred dollars
. `($100)mless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cerfythat In the pedormanceof the work(orwNch this permit is issued,
I shall not employ any person In any manner n as to become subject to the (J
WATER syS /TREATING
Workers'CompennHon laws of California. Date �• J PAID ` aQ
_ O Z ApplicantNEWRESIDENTIAL PLMO. SOFC. Dale Reoet t# �r/
Z O NOTICE TO APPLICANT.E,afte,raking this Certificates of Exemption,you
should become subject to the Workers'Compes+dors provblom of the Labor TOT
N Code,you must forthwith comply with such provisions,or this permit shall be I DING FEE ,
W y deemed cooked. BU
G CONSTRUCTION LENDING AGENCY SEISMIC FE
CL Z Ihereby aftlrmthat there la a construction lending agency for the perform. TOTAL •O ELECTRIC FEE
ante of the work for which this permit b Issued 15m.3097,Civ.C.)
LL OF u flees Nam
ddmss QTY. MECHANICAL PERMIT FEE PLUMBING FEE .2x(•00
LL MECHANICAL FEE
ion
O W rmrt.Iagree to e mad comply with
al atianand dcountyordinances edgatertws ,O
a Lsmirgt buildingcomplywlthandheredmuntyordinanasandststelaws PERMIT ISSUANCE aZ, Uf/ FEES PAID: .j,y,�X
} rey0ngtobuilding t a abvctian,+ndhdreby property
in representatives of this
H N city to enteruponand
property forinspe Cit purposes. ALTER OR ADDTO MECH. -(Jp
Z c no save,Indemnify an d keep harmless the City of Cupertino Date Recei t#
V agaWtuab ,judgments,cestsand expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 GEM)- SUBTOTAL:
against•aid CI In consequence of the granting of this permit 9 yin
/ AIR HANDLING UNIT(OVER 10, W CFM) CONSTRUCTION TAX
S mmie of Ap Rant/Contncror Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS OI SCLOSURE
Will nhe pliant or mtum building occupant snore or handle hacardous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
s defined by the Cupertlo MuNtlpal Code,Chapter 9.17,and the
Iiealthand Safety Code Serio 7(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
qYa
e r rare building occupant use equipment or devils VENTILATION FAN(SINGLE RESID) ro ISSUANCE DATE
which emit haeardam air=is mirarat•as,ciefned by the Bay Area Air /���
ality Management Dlstrid? BOILER-COMP DHPOR IOO,000 BTUI PPJD
(�L�Yn n No
`` - iMve read the haxar�ousmalerab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) r�� t u 7!}�l
the Califemla Health&Safety Cade,Sections 25505,25S3 and 75534.I l 1 3, V /3 1
u If the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff.
rnpovlbl➢yto iy the occupant of the requirements which most be met /a�
prlorto ce a ifi te,otOccupancy. UId of w
"Y / 9/
Ow eroraunho agent , Dale T ISSUEDBY:
TOTAL: �V
OFFICE COPY,