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21253 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY Building Proaat Identlrlotl® PERMIT NO. Building Adds: 21253 z F�L_ roti VJv. uPt�, 1� iera Gz" \R-Wito2739 one. CITY OF CUPERTINO-BUILDING DIVISION q Contrsciur'm Name: Uc.No: APPLICATION I PERMIT e- 3 �-- ( d 1r1r W BUIUXNGL ELBCTRICAPLUMBINGMECFUNICAL CATEGORY CONTROL.M I` ArcFBea/Finglnar. LX No: Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION PERhfJTISSUANCE Ikrcby af(Irm than[.m kerueduMerpm'vblonadCluptcr9(mmmrn APPUANCESRESIDFNTIAL )OBD N Ingwlt 11.Is in simufi,rmfon .!DiWslnr3dlheBudnemandProlesd¢uCMe,andmy nr¢end dred. PANELS be k Date Comnci � `"`T rk77 0 , ARCHITECTS DECLARATION mofioA.Mps 0 C7 I understand my plans sI used a publier mia OVERIII(IOAMPS SQ Fr.FLOOR AREA f/9�.FT. U Lkensed PMealovl tSIGNSELECrRKAL OWNER-BUILDER DECLARATIONI.�G Ihercby a(Bnnthat lameaempt lratnthe GOMraGOri LI¢mlAwfortkoRga. eon , umineraMPmubvCode:Mydtyor gpanyatrudure prbr to itsbwnce,also requtrethe appbant(¢much prmdt to Ne a signed statement that he b licensed pursuant to the provbbv of theOContnnor's License Law(Chapter 9(meurendng with Scrfon 7000)of DM- 5 ebn3 tithe BuMeaand Prde:bv Code)orthat he h eaernptthendmmaM VALUATPN the b.Im for the alleged eaempibn. My v1a d1un of Sodbn 7m1S by soy a} O(� <5. ppU.tf.rapen .b*utheappLr tt..d l pevltyd.&.mthan OUTLETSSW[TCHESFDMJRFS (la Qv� drMdNlum%W. NEW RESIDENTIAL ELECTR SQFr. �hf�namoweril otproperty,or myemployeeot"It mween am their sole 7Y1'E CONSTRUCTpN 5 e6m CSm.70 n,wllldotk w«kand the.COde:¢heC Welled.famedfor 5 F O nit(Sec 7p ly B son cv,and Prdesbns Cade:The C improw s Ll¢ve Ianw dm notapplytoanowvlf pthmrtywho wfidsorl prostkrmgand OCC.GROUP RFS.UMTS whodaea Ontsam khlmseB«towel,MsownemplgeQ prwhel,thatsuch improvementsartrad Intended earofecd ptsale.If, owue fker NNaw TOTAL: Imp v mere bmoldwllhlnovynrofcompletloNtk owner-bullderwlB have ben of proving that he did not wild or improve for purpose ofulm.). QTY. PLUMBING PERMIT FEE FLOODADNE APN Lj L a owner of the property,am erchnt rly mntmeting will,Boenrtd PERMIT ISSUANCE eneurmetmm to mnstruet the project(Sec 7DµBualnem aM Tkorexloa Code The Contractors License Law doe not apply to an owner d property who AL]II(-DKA W k VFT[-WATER(EA) Wilds or Imp-ve thereon,and who --tract' fee much p�o)ece with a I1{anaed pursuanlb NeCrntncids Llarvel.w. BACK FLOW PROTECT.DEVICE FEE SUMMARY I"K1 men eypt under S B&P C forthisreason Own< / --e QJl3/�Q DRAINS FLOOR ROOF,AREA,RIND. SANITARY Y_ N_. WORKMAN COMPENSATION DECLAR TI RECEITT a ❑I hereby affirm that I have a certificate of consent to wiftneute,«a FDOURES PER TRAP SCIHi TAX Y_ N ¢rtlOate o(Workers'Compevatlonivuree¢«a anifkd ropy thereof pec. RECFR'I'It 38Lab C.) GAS EA.SYSTEM-1 INC4 OUTLIIB PARK 0QFEE Y_ N P�IIt COC ray GAS EA.SYSTEM-OVER 4(EA) BUI L DINNDVIS ION I'EES I (Certified copy b hereby furnished.Nshed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE ' rL�J9 Certlfiea-py b filed with the tlty 1-pectlOn alWsion. CERTIFTGTE OF EXEMPTION FROM WORRIERS' GREASE TIW' PAID COMPFNSATIONINSURANCE SEWFE SANITARY-STORM EA.2TOFT Date Recd t# (rMm,mena) need era wc.mpldcd Utk p.rtNt b(«av hundml dollars (51 O])afy,th WATER HEATERW/VENT/ELECTR ENERGY FEE Y_ N 1¢nore ploy an person so as to Corm,suNblwed, — I shall fiat employ any perm*In any manner at a to beco*r�bjnt to ti; WATER SYShM/TRFATTNG W«Vera Compensatbn Irtws of California. Date PAID O = Applicant NEW RI'SIDENTW,I'WfB. Z O NOTICETOMI'LICAM:If,after uul<IngtMsClrtBlateofExemptbn,yw SQ.FT'. Date Recti t# a midbennesub)mbthe WOrkm'Compevatianpmvbbvofthe Labor Code (orthwilh comply with wch provbbv or this pemd[shalllx TOTAL: •OO voloed. BUILDING FEE a p CONSTRUMON LENDING AGENCY SEISMIC FEE I ( IhembyafRmtkttk¢bamrutmeimkmingage* = C1v.C.)Mcy fortk pedorm TOTAL ELECTRIC FEE 6na olthe workforwhkhthis permNb Wiled(See 3p97, Q 2 Lee'.N.rre PLUMBING FEE LL F Lenderi Addnm QTY. MECHANICAL PERMIT FE MECHANICAL FEE O W torr thatl have read thbapplleatbnaM samthat the above lnfomutlm b mrreci-Iagree to vith.B city and rountyordlnanamand state lu. PFRMITIS5UANCE $PAID: ' r N ,¢Iatlry to wilding rormroGlon,aM krcby authadze rcpresentativn olthb F Z dty to enter upon the alo nnentloned property for lrupectbn purp.�s ALTER ORADDTOMDM. — i (We)'gra to saw,Indemdfy an d kap harmine the City d C n,ro Date Reeei t# galvtt WbiWks,ydgn�nb,mats and ePerunwhlch omylO anywayamue AIR BANDUNG UNIT D O 10,ODOCF'M) SUBTOTAL• galmt eiCityln of thO granting d tMs permit. _ Z ATR BANDUNG UNIT(OVER IQODO CFM) CONSTRUCTION TAX a e m f�� r/e nlnrt« (� to EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE WBltheappB¢mt uta¢wildingar pantstomorHMleha ms HFATWCIIMTTO100,0 IBL() Date RCCei t# mslerlal as dOBvd by tk Cupertiw Mu Ncipal Code,Chapter 9.1;end thO HeehhaMS,feyCode Seeti.25537(p)7 HEATING IJt,,7T(OVER 100,000 BTU) TOTAL: •� INE Yn No Illthehapplic, rand Ne turcwildingo-vpantuby the Bay Area VENT[fATTON FAN SINGLE RE9D7 1$$U TE hkh eMr rase Nous air-ntaMvNs ae deBred by the Bay Arta Air Qualityy MavgemeN DidnM7 BOII.FR{OMP©FB'DA 100,000 BTU) Vn No ave OCT read matertabrc requirernrsunderChapteri9iof BORER{O.V.P(OVER100,ONBi11) 'II IW!P un en lfomla heath&Safety Code,Be llore 25505,have a t and 25531.] uMenteMthat iftkweocoupm not herre.1rernrda tenant that it bey NEIN RESIDENTIAL MECH. 9QF7 rapovmso'mof. theOwpaMdthe rt9"UcmeNawhkh wxk roti prior to L9suan<e d a CeNfkete of 0¢V parry. Owner Or authortred agent Date ISSUED BY: t TOTAL: OFFICE COPY