21822 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buil,fle,Proeat Identification PERMIT NO.
B°ildirigCc
Add.: 21822
ass i F�
/ �N ✓� , s r-. a GQ 9so i
EJ{•�>ELi2 {'1Ll✓7 CITY OF CUPERTINO-BUILDING DIVISION —Z��—a I
ConMacbrb Na ci�rF Lk.Na APPLICATION / PERMIT 1
BUMMNGELEcnuCALI'LUMBINGMECHANICAL CATEGORY CO O
Arehftec/Fsglre .. Lk:No:
QTY ELECPRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE X71 ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION LL
I hemby affirm that 1 am Iteeneed under pr.vsions f Chapter 9(mmmmc APPUANCESRESIDENIIAL
JOB DF_9CRI1'IION
ingwith Section 7000).!Dlvielm3 o/the B"neuand Prof W.nsCode,and my—
lieenae s In full forte and eft PANELS
Lion.Clam Lld1
Date ComvRor —UP TO 200 AMS
ARCHITECTS DECLARATION 201-1000 AMPS
a0 7. I urdentand my Petra sballbe used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
COC
U LknesedP .Lorin SIGNS ELECTRICAL
a OWNER-BUILDER DECLARATION SpEC7ALCIRCUIT/MLSC
Ihvmbyaf .that lameaempt from the Contractor's Lkense law for the
�go qqqq felbvMg rtasan.6ectior70015,Buslnea and Pmledons Code:Any dry or
munywhbhrequtmaper tommbun,a)Ier,impm ,dem ,.rmpM, TEMP.METER OR POLE INST.
�4a anypm=mprbrtoibbara alsorequirntbeappgantfmath pemJtm POWER DEVICES
{�{��
file a wiped Wtement that he b lkers pursuant to the provbbnu of the
with
Divi-
lb vbn3ofthe Bualn¢aand P mniuru Cod0orth�leeaempttherefrompnd SWIS(MING POOL ELECTRIC
3 <.•i]] VALUATION
the hiss for be alleged exemption, Any Wdatbn of Section 70715 1y an
O appli !fora permit vb"theapp"mtoadvilperaltydm
ndortthan �F IS.SWt,rcF�TrFl)m1ItE5
�Ooo'or)
M dred ddsn(SSOf/.
R eI,as owner Of the property,or my empbym with wages as their sole NEw READFMi'V'ELFT'CR SQ'FT' S 0MES TYPE CONSTRUCTION
oompereetion,w0ldothe work,andtheesurtu¢b not intended or oHemd for
oBaleCSee 70K Busineuami Pro(eaions Code The C.irma=e.License Law -
93 don cot apply to m owrcr alproperty who builds or improve thereon,and
o'^ who doessuch work Mmaelf or through hie own employm,provlded that udt OCCGROUP RES.UNITS
improvements art not Intended oroffened for sale.If,however,the building or TOTAL
Improverrcra bnold wkhinomyearofc ryte Wb thea -bullderwill have
tlyekundm of proving that he did not build or improve for purpose Ofsate.). QTY, PLUMBING PERMIT FEE
LJ J,u owner of the property,am eachufvety conn deg with Ii¢nad FLOOD TONE APN
mntnctot to mnsbud the pmjed(See 7044 Buanus and Profesbns Code: PERMIT ISSUANCE
The Contractor's License taw does not apply to an owner of property who
builds or Improve therms,and who convracta 100 undi pr.)eN with a ALTER-DRAIN&VENT-WATER(EA)
ry�a�tor(e)R¢rued pursuant to the COntnbds Llcorue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
01 am a empt order Sec B& P C for this rtunn
OUTS1 DF FEES
DRAINS R, A,FLOOR ROOF,ARECONTI. SANITARY Y_ N_
Owner Date REM'R
WOR IaNAN COMPENSATION DECLARATION FIX.IVRFS PER TRAP SCHOOL TAX Y_ N
❑1 hereby aff m that I have a¢r to of couentto self-Wu¢,Ora R_ N
¢rtlflabC.) ker'Comperwdanlwnn¢manrtBfed mpytherto((Sec. GAS FA.SYSTF3rf-1 INC OUTI.EIS PARKFEE Y N
3400,lab CJ
mkY` GAS FA.SYS"CFM-0VFR d(EA) RTCFIPT/
� y BUILDING DIVISION FEES
Ce"IRed copy s heed with fished. GREASE/INDUS IRL WASTE INTFRCEPCOR PLANCHECK FEE
❑Certified copy b filed with the dry inspection dlvWm.
CERTIIICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWMSANTTARY-STORM EA.XaE C. Date R-Qpt# IsZ�
(fhs section need not be a ropteted Rthe permit s!.sore hundrod do0am
fSt m)orfea) WATER HEATERW/VENT/ELDC7R ENERGY FEE Y
I¢notify thatInthe person
Mthework fors to beospemdtle boned,
1 o k not empty any t L w% In any canner so u to become onbjeat to the
W AlIR SYSTEM/TAFA77NX;
W¢kcanCompenvtbe laws o/G11(ons.Date PAID
Applicant
Z NX3TICETO AI'1'LICANT:H,after making this Certlfkate of Exemption,you NEW RFSIDINIIAL PIMB. SQFT. C'ml t#
O should become abject to the Worker Compensation provisions ofthelabor T TA L:
N Code,you muItfothwfth mmpy witheu&pruvsiom.rthb profit shall the 1 sGp
W > domed revokes. ELL
CONSTRUCTION LENDING AGENCY SETS IC FEE t
d Ihembyaffimn Hut then b a mnstroctim lendngagency for Hu perform, TOTAL. ELECTRIC FEE
7 Zanm olthe workforwhkhths pemat s lseued sec.3097,CIv.C.)
00 fender's Name PLUMBING FEE
LL ~ Ie.dee Addrtm QTY. MECHANICAL PERMIT IEE MECIiANI(5 L FEE
O W I¢rtiytlutl havereadthsappllabbnaM amtethsttheabove lnfomrutlm
1 smM
m .I.grmtocomplywXW dr
hyand muntyordlnanmand statelawMIT
w PERISSUANCE FEES PAID:
>. IL to Wilding mmtrutll.e,andhrebyautherte repmeentathes ofths
r city toenterupon the above-mentbnRd property for poctlon Purpu . ALTERORADDTOMECFL
U) WDate Recel
agmar
cto. Inde andkeephms.the Clty.f Cupenlno
() .Be. bWtln,)adgrnons, Mupensee whkh myb any wayamue AIR FIANDONG UNIT(TO 10,000 CFM) SUBTOTAL! -
AX L:
acRyumneeq.e the gnnuingf Wapemdt. AIR FIANDLING UNIT(DYER t0,000CFM) CONSTRUCIIONTAX
7 \
wrt.rA puanv radar Date IXFIAVST FLOOD(w/Duca CONSTRUCI70N TAX 'AID.
HAUR US MA RIALSDISCLOSURE '
the ar 'mofutu acapant sort or l�rdte M1aramlaus 1-IFATING UNIT Im,mO BTU) Date RCCci k
me ria red by Hr Cupertino Munlctpal Cade,Chapter 9.1 Z and the ^I
I Ieahh and Safety Code action 25532(a)7 HEATING UNIT(OVER 10(L"BTU) T AL• el
1—I Yn IVB re
Wmit applicant¢ curtbulldbgoompant use equipment or.Air, s VENTILATION FAN SINGLE RFSID) I$SUAN
whkh emit Fuvrdoue air mnbmwnta as defined by tM Bay Ana Air
Qu_allty Mavgcmrm 047
BORER-OMP PHPOR 1m,0(q BTU) �a• j al ��,�F�
4 Yn No 4 fI cip
have reed the Faun our matenas nequlremenb under Chapter 695 of BOILQt-COMP(OVfR 100,IXD RN)
the Olifons Health&&fey Code,Sect m75505,25533vd25536.1
'i understandthatilthe ingdxs noturently have a tenant,that it boy NEW RESIDENTIAL MECH. SQ.FT
rapo =rot malty eocmrpaof& a Irtmienb which must be met
p uancc of !late of
norm .rived agent u
Date TOTAL: ISSUED BY:
OFFICE COPY