21522 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
buildInA Project Identfkadon 7 NO.
Bullding Address:
(00 O —/ /,vocn4 On I 21522
CITY OF CUPERTINO-BUILDING DIVISION
c«dretlayyName: Lk.Na APPLICATION / PERMIT L2'�"YA
-� l/r/ .s•4. �'T�£aL A.ISL '2473° BUILWNGMBCMCALIPLUMBWGMFAiAMCAL CATEGORY CONTROLd
AmhhM/Englnaer. Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 1�1 PLUMS MEM
PERMITISSUANCE ❑ El ❑
LICENSED CO.NTRACTOR'B DECLARATION
I MSed fmothatl smllcenxduMerpr WmsofChapler9(mmmme APPLIANCESRESIDENTIAL JOB DFSRIPTI N
lo
IngwlihSedn7000)of Dlvldm3ofthe Bus and Pmfe- -m Code,and
I'r b In h PANELS
to d ,,# r�G //
Dat �� Cohn•c/ctor Iceb a, UP
ARCHITECTS DECLARATION 201.1000AMPS
0W'Z naI undenfand my plana shall be used a public records. OVERI000AMPS SQ.FT.FLOOR AREA $/9Q.FT.
L LlceedmS
Pkslorid SIGNSEIIRICAL
«<< OWNER-BUILDER DECLARATION
l ham exempt that l aexempt from the Cords tors Lkcnae law for the SITLNLCIACIlf7/ML9C
following reason.(Section 70015,Bushes and Pmfesbres Code:Any efty or
TE]N P.ME[TR ORIOLE A`ST.
K� muntywhkh requires•permit tomnawct,alter,bnpmve,demoWh,orrrpalr
��[[ < Inyetrocture prbrto lb bwarce,aWrryulrvtheappllcant(«wch pemdt to POWER DEVICES
K O 01e a WPed statement that Mb llaenaed Purwnt to the pmvLalona of the
Oe. Contractors fire—law OC pter9(emornineingwith Section7000)ofD1v1-
�OS SWIMMING POOL ELE
elon3o11he Businese and PrefesCode)orthat he b exempt m
pt therefmaod CTRIC
bna VALUATION
the W sb for the alleged exemption. Any violation of S Jou 70315 by any
<5 app0ont fora permit wbjxLtheapplkanttoa civil penakyofnet morethan OUTLEISSWIICHESFIXTURES
five hundred dollen(5500). NEW RESIDlN1TA1.ELEX'fR
❑1,as owner of the property,or my employes with wages as thele ole SQ17. STORIES TYPE CONSTRUCTION
c roPenartlon,will do the w«K and the trocture b rant Wended or offered for
o vie(Sec.70K Buainass and Profeslona Code:The Coareaors Llnme Law
$ don not apply to an owner of property who bullas or improves thereon,and OCG GROUP RIS UNITS
dm such work himself or throughw
hlson employees,Provided that each
ImprevemeNs are sat Intended cooffered for sale.If,however,the building or TOTAL
improvement bolo within omrarofcompletb theowner-b Uerwi8 have
tit ,'den of proving that he did not build or imprmi,for purpose ofsale.). QTY, PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively contracting with licensed FIADD ZONE AM
mntntors to mnatrod the pmject(Sec-70K Boslneseand Pmfnsbna Code: PERMIT ISSUANCE
The Contractors Lleen x,Taw doe net apply to an owner a property who AI.TER DRAW 6:VEM WATER�1J
builds or Improv thecer, and who maracta f«weh p," whit
rylltpator(s)11¢ nm
esed pe to the Cemry '.Lieenae Law. FEE SUMMARY
LI I am exempt uMer Sec B k P C for this reawn BACK FLOW PROTECT.DEVICE OUTSED
•
Owner Date
DRAINS FLOOR ROOF,AREA,COM). SANITARY Y_ N_
WORKRICEarrMAN COMPENSATION DECLARATION F0(�S PER TRAP Scld TAX Y_ N_
❑1 here(affirm that 1 have• Boa's to of.ctodit di elf.impere m
anNate of orkm'Compeneatim lnaurana ora¢reified mpythereof(Sec. RII'EPIE
3B00,Lab C.) _ GAS FA.SYSTEId-I INC,40VILEIS PARK FEE Y_ N_
Pd e 0 S13 G ens Fw.SYSTEM-0VER 4(EA) REcm'I s
Comm any V'.-a a BUILDING DIVISION FEES
Iafl Certified copy b hereby famished. GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
L9ccetlfied copy b filed with the city inspection division.
CTATIHCATE OF EXEMPFION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE Nfo gEW.p�ySANTEARYS10RM EA�T Date Reed tR
(IMI I..) needfid becomported 1!the permit bforon hundred dollue
(5100)«ytha WATER HEATER w/VENT/ELWR ENERGY FEE Y N
(certify thato they pe.I mofthewmk forwNohtmI subjb Wued,
T .rkhaln«employ any Peron in any manner so as to becosre object to the WATER SYSTEM/TRFAT1NG
Worken'Cmipenaatlon Ir.vl of California.Date PAID
O Z NOTICETO t NEW RESIDENTIAL PSB. SQFL Date Recel t#
Z O sheeld Econnesr1.ICAtothe after maklompar Catjo pro is Exemption,you
� N ehmld become object to the Wohen'Compenaatlon provisions of the Labor TOTAL:
Cade you five f«lhwith�,py with wch prwblona°,'thio peons shall be
� > deemed rewaked. BUILDING FEE
IL a CONSTRUCTION LENDING AGENCY SEISMIC FE
Z
CL I herebyamrm thatthere b a miemdim lodmgagency forthe perform TOTAL: ELECTRIC FEE
an oftheworkforwhkhthlapcmJtbb.> (Sec.3097,Clv.C.)
V O lanae,'.Name PLUMBING FEE
LL F Under.Addrma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O IU I mtlythat l have read thbappUcatbn and tatethaithe abovelnfonrsdm
bcomed.IagreetocomplywdhalltltyaMmunty0rdlnmcvandewshawl PERMIT ISSUANCE �'1,� FEES PAID.
>. N relating to bulkling mrWm¢Ion,and hereby authortr,e repexentatives of this
F Z tltyto entero shite above-mentioned Property f«kespectiun purpose. ALTERORADDRIMECIL Date Recei tie
(We)• to save,Irde y an d keep harmless the City of Cupertino
V .groat tkn,pdgmeo .px.vvhkhmay1rany.y.. AIRHANDL1NCUNTT(TO10,000CFTU SUBTOTAL:
agalnat styU a of grsair,g died.permit G AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
re pE fit/Contract« Date D(HAIhTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DISCIASURE {y�
WW the applleant or future buRaing oavpant store or ha Mle hawdois HEATING UNIT(TO 100,000 BTU) t `� Date Recei Ile
material as defined by ted Cupred.Municipal Code,Chapter 9.12,and the
Health and Safety Coder.-S�ection 255324)? HEATING UNIT(OVER 100,0DO BTU) TOTAL:
❑Ye u No
Will thaappllaa or future building oavpant use equipment or ri v VENTILATION FAN(SWGLEREsm) ISSUANCE DATE
whkheMtlsvrdwsabmnua measdefinedbyted Ny Arca Ab
QualRyn anagemea lYsttct7 BOILER-ODMP OEPOR 100,0M BTU)
4YY No
heve read thehaa matetab requlrenrentsunderChapt r6.95 of BOILER-COMP(OVERIM,00DB'M -
tkGlBornb7lmHhfiSafsty Code,Smlona 25565,25533 and 2'v]l. I .t
uMentandy,to notify the ongdaes of therreuiremees hick, sit it bony NEW RESIDENTIAL MECH. SQ.F7, rL Cs V �J!
pf to e0ity to notify the oavpantathemqubnrnew which mut be rrct Qr..r1
pt to Lsuanma Cetlf co/0mvpanry.
19-6
Off+ o�f�l1y1�"c � L7�3lCd
ser«out °rias agent Date ISSl1EDRY: V IJPiY/V7-/t
TOTAL x
OFFICE COPY