21565APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Idemtmlcatioan' •�
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PERMITNO.
21565 1CCC
nes ams: -1 /J one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUiLDINGELECTRICA PLUMBINGMF LAICAL
A A A
t
l
contrs"° � me:Lie. No:
CATEGORY
CONTROL N
Architect/Engineer. LIc. No:
QIY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/�--a� ( w
Addmss� 3�s I/�/S'�JO� >d1JJfCG)
l PFRNUTISSUANCE Irz cz
�..
- E] IK 0 E
LICENSED CONTRACTOR'S DECLARATION
I hereby affurn that l am lensed under provisions ofChapter 9 (comenene.
hec..h I.forceando"a°n3o(the Buslneuand Pmfesslona Code, and my
liana ?Class (once and e. #
Llanse Cbss LICK
APPLIANCESRESIDENLIAL
PANELS
TOB DESCRIPTION
Date Contractor
f+r
20140DOAMPS
ARCHITECT'S DECLARATION
1 understand my plamahallbe used as publicrtomIL
OVER1000AMPS
SQ, F7. FLOOR AREA
5/SQ. FL.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hffi
thereby arm that I am exempt from the Contra ttoea Licenx Taw fw the
e crscrULC1RC /M
Ii SO
7FMP.MEIFRO PO It \
pOW'RDE-VICPS
following mason. CSottlon70315, Businessand PmfemIcan Code: Any city or
ceuntywhich aquina Pemdttocomt,M alteq Improve, demolLh,ormpatr
anystuctum prlorto its Issuance, alsorequbem theappllant f.rsuch permit to
file a signed satemmA that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Settioo 7000)of Divi-
al.n 3 of the Business and Pmfemlem Code) or that he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 701.5 by any
applicant cora permttsubjeets the applicant to a civil penalty ce us room than
five hundred dollars ($500).
r-1 1. as owner of the property, or my employe.. with wages as their sole
SWIMMING POOL TIC
VALUATION
t
0[JILETSSWI }I
1
NEW RFSID LEC BO
STORIES
TYPECONSTRLICTION
compensation, will do the work and the structure is not Intended or offered for
N1 I
vie t5ec. 7064, Business and P felons Code: The Contract.?. Llaue Taw
doesnot apply to an owner of pmpeny who builds or Improves therm.., and
whod°esauchworkhn lfwthwghhbownemployaa,providedthat Rsch
6CGROUP
RES. UNITS
impuvermnbamnat tendedoroffemdfwule. If,h°wevcr,rhebuilding°r
improvement ismld within oneyearofcompletlon, rhe°wner-bullderwlll have
tLV-L .. of proving that he did na baud or improve for purp°x of sale.).
I, a owner of the Property, am exclusively mntracting with licensed
co ctors to mmtuct the project (Sec. 7064, Business and Profs..ions Code:
TOTAL: t Q
'
QTY, UMBING PERMIT FEE
PERMIT ISSUANCE
F7.Opp PANE
nPN
The Contrsner'a License Taw does not apply to an owner of property who
Wild. itch er Improv.. thereon, and who contracts for such p(ojem with a
cc&etor(s) Bcenxd pursuant to the Contractor'. License Law.
inI am exempt under Sec. B k P C for this mason
ALTER -DRAIN k VENT - WATER (EAI
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
O.vncr Date -
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRMSCI100L
SANITARY Y N—
RECERT#
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to welt -Inca, or
TAX Y N
wniticate O(Worke Com rmtion Wuranawacenlfindmpythertof pec.
MOD, Tab C.)
Policy 0
RECEIPT#
GAS FA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
Co
E. -)
BUILDING DIVISION FEES
ifed copy Is hereby f arolahed.
❑Certified copy is filed with the city Inspection division.
GREASEANDUSLRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thb&cctMion ncna be completed lithe permit V (.rota hundred dollars
PAID
Date Receipt
PIk
-
SEWER-STORMFA 200FL
($1M.,loss.)
cent that o any pehe omanca any
eesubjeetmit 1. to the
I
I shall not employ any person f any manner m u to become object to the
manner an a to become
W°rkcrn CompevaHon Taws °! California. Date
Applicant
NOTICE TO APPLICANT: If, ager making this Certificate of Gemptlon, you
shuld become subra t. the Wor4ers'Comperaation provisions of the Labor
Cod, You at forthwith comply with such provisions or this permit &hall he
deemed revoked.
WAI.EAHFA.lFRW/VFNT/E].El=I7t
ENERGY FEE Y N—
—
PAID
Date Recei to
WATIR SYSTFM/TRPATING
NEW RESIDENTIAL PLMe. SQF7,
TOTAL:
BUILDING FEE
TOTAL:
CONSTRUCTION LENDING AGENCY
IhembyaRlrm that them ea construction lendingagenry?.ribs perlorm
once °?the work for which this permit Is boem d (Sec.3(IYI, Clv. C.)
SEISMIC FEE
ELECTRIC FEE
lender's Name
lende?s Addrt&&
I ecrtlfythat E have read thisapphutionand gate rhattheabeve Nformrtion
QTY. MECHANICAL PERMIT F[E
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Lscomet. l agree to comply with all city and mussy ordinances and sate law&
relating to building construction, and hereby authomm, representatives of this
PERMIT ISSUANCE
city to enter upon the above mentioned property for inspection purposes.
(We) agac to rove, indemnify an d keep bared. the City of Cu pen ire
age rbaab'I
ilillitio.j.Ity``'me' is penx which may In any Way an..
gra. 3WQ �J
IG
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10," CFM)
Date ReCet t#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER I0'W0CFM)
CONSTRUCTION TAX
Sig atvrc.f Applicant/Contractor Date
EXHAUSLHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TOIW,ODO BTU)
Will the appllant orfutum building occupant store or hand to haaardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date RCCeI tR
HEATING UNIT (OVER 100,000 BTI)
TOTAL:
1- fes lth a nd Safety Code Section 25532(.)7
❑ Yes r] No
VENTILATION FAN( SINGLE RESID)
isAN TE
('I C'l:
Will the applicant orfoome Wildingecmpant useequlpment orcievias
which emit hat rdous air mntaMnants as defined by the Bay Are. Air
Quality Ma tugement District?
4 Y.. F� No
have read the ha cus materials requirements under Chapter 6.95 of
BOILER -COMP OTE' OR 100,0M BTU)
BOILER -COMP (OVER I OO,OD) BTU)
the CMercla l lealth A SafetyCode, Sect ions 25505, 25533 and 25534.1
QEG 1 O Jaw
NEW RUJDENTIALMECH. SQ,E7,
Understand that lithe Wilding docs not currently have a tenant, that it is my
resp°nsinal/ytheaoftherequirement&which must be met
prior(. Lmuance of Certificate of Occupancy.
ISSUED BY_�y)\�{� -`-'�
Owgen
necor.uthoriudat Dino
TOTAL:
OFFICE COPY