21414 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
EulldlitProject Identification PERMIT NO.
Build
@gAdd rean� 1 21414
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a . one:
� ` p _&2 aCITY OF CUPERTINO-BUILDING DIVISION
• �or.Nam: Lic.N& APPLICATION I PERMIT
�7���CCvri BUfIAiNGF],pC'IRICALrLUMBINGMBCFIANICAL CATEGORY cOVIRDLR
Archhel/Fsgtrcer. Lk.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu PQOrBTISSUANCE ❑ ❑ ❑
LICENSEDCONTRi under BDECLARATION
I hereby Sectio lr 00)of that 9Jo,,3licersofthe rprovLstons of Chaper9lmTnmmc ArrL1ANCFSRESIDENitAL B RIPIION
lice lat fun7000)otDlddm3ofNe Budnossand Proleedans Coda•red my
Li lt In(u0 r d effect rANEIs
Date- CFI[T•aor �ARATIO-.�/1.
UP TO 2W AMPS
ARCHFI be tua DECLXRATION 2T1-1000
Ore 77 I uMerstand my pons eha0 be used n public rtmnds OVER 1000 AMPS SQ.Ff.FLOOR AREA 5/SQ-FT.
G [j Licensed Profeeslarul SIGNS ELECTRICAL
;1 ibJl OWNER-BNLDER DECLARATION
Ihenbyaf eenthatlameaemptfrmnthe Contrano/e LicenseLw(m the =ULCIItCUIT/MISC
following reason.(Seel.7015,Budne s a Profenloru Code:Any city or TEMP.METER OR IOIE COST.
r� evnntywhkh requhea perniond tomrutmq alter,Improv,demolish,orrepalr
any structure pdortolts issuance,alto requireitheappllont fmsuch permR to POWER DEVICES
ryL fate a dgnad statement that he b hcensed pursuant to the provisions of the "
Contractor's License taw(Chap,er 9(mmmenring with Sect on 7000)of Divi-
3 < abn 3 of the Buslnm and Professions Code)or that belt eoterapt
therefrom and EL
SWMNUNG FOOL ECPRIC '1 VALUATION
the baals for the alleged e•emptbn. Any solation of Section7015 by say / \ - a
ppile"tfora perm0 subjecstheappllcanttoa cfWl penalty of not morethan O(m"�S EIFSETXRIR �� L {/
hundred dollars(5.500).
a
1,ase owner of the property,or my employees with wage as their sole NEW RF3DINIIAL EI.FGIR SQFr. STORI TYPE CONSTRI1CIlON
romperustlan,wRldothew¢k.and Nestrvcturt isnot ln,eMcd our o(!e d$ A s o nit(Sec7011,Buslmssand Pmfmlom Code The Contnnoteucc
Pj, SS on t apply to sou owner of property who Wilda or Improves pros thereona-
e
F whudosuch work hlnmelforthmue
gh hleown employe ,provided that su 'a " OCC.GROUP RES UNITS
drot
Impmvemenbannotlntendeaoroffertdfms .H,howe rthebud"g s I F TAL
lmprovemem ltsokl whh@arcyearafcompletbn,tteerwner-builderwW r'
dICjIurden of pmdng that be,did not build or triprove for purpose clinic.). PLUMBING PERMIT FEE
FLOOD ZONE APN
I,ase owner of the property,am essh4,wlyBud c sort ing
with Ilarodd PERMIT ISSUANCE,! "
the Co ms to Contractors
License
,he project(Sec 7010,Businm ate rrdmbro Code
The .1 imprs Llo then Lw don not apply,o an owner d property,who ALTER-DRAIN It VENT"-WATER(EN
W Ills or Improve thesoq and who mrdnRa for such ptoJem • (i
Boened pursuant to the CmtnctoYs License I w. RACKFLOWPROTBCT.DEVICE FEE SUMMARY
LJ I am evempt under Sec B 4 P C for this reason
ES
Owner Dde E,R&lrjS.KMHDOR ROOF,AREA,GOND. SANTfARY Y— N
�' R
WORKMAN COMPENSATION DECLARATION REC ITT
— N_
F-11 hereby affirm that I Farr•¢stlfloo
te of cuent to self-Twatm, a TRAP SCHOOL FAX YRKEEPT R
¢rtwota of Workers Cmnpenudmnlnsunnca ws¢rtl(led mpythermf(Sa. GAS EA.SYSTEM-1 INCROUTLETS PARK FEE Y— N_
pak
�6G ?
Po11cy I OG 3C 5/2 -1 DING D R
�Cy �fi GAS EA.SYSTEM-0VERt(PA) BUILDING Oi VISION FEES
ertw coped y b fiedwoby th the city
d. GREASE/WDUSIAL WASTE INTFJ2CEP'IOR PLANCHECK FEE
❑CertIRM ropy lt filed with the city 1nspeGlon dlWdmi.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION DISURANCE SEWI]t-SANITARY STORM EA XI!&-1. Date Reexl tM
Tfhlaacctbn neM not be<wnpieted Rthe pemdt V foorc hundred dollars
(53 00)or lm.) COATER I-�ATFR w/vFxr/ELEc'rR ENERGY FEE Y N
]¢dBy tha,in the perfomun¢of thcwmk for which this pemdt b lasted, —
I had]nIX employ,any person 1n any manner so as to brmme subject to the WATQt SYSTEM/TIiFATIIx
Workers Corn maHnn laws ofC hfomla.Date PAID
O Z Applicant
Z D NOTICE TO APPLICANT.If,after makdng this Certificate of Exemption.you NEWRESIDENE7ALPLMB. SQFr. Date Recei toy
should become subject to the Workers'Compewtbn provisbm of the Labor TOTAL
~ _) Cod,you atf¢thwlth rmnplywith such povltbns or this pcmw dull be
LU > dwe revoked. BUILDING FEE
W F3 CONSfRUCT1ON LENDING AGENCY 5EISMIC FEE
d therebyafilthat there 6 a construction lending agency for the perform ELECTRIC FEE
Z an¢ofthe workfor which this permit lt Issued lSK 3047,0,Q TOTAL
02 1<"aer'Name PLUMBING FEE
1L F Iardc.awddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢nlfythatlh wmadthbappLat naMoat tH theabove@rormnim
bcorrcat.I agreetocamplywlth all cityand countyordlnnnmsand statelaws PERMIT I99UANCE FEES PAID:
>_ N Matingto Wlldmgmm dim,aMh mbyauthm mpr ntattveofthb
F Z city to enter upon theaWvcment@red property for inspection purpose. ALTERORADDTOMECH.
(We)agree to save,WemNfy an d keep brmlm the City of Cupertino Date R2 Ci toy
V ag.W,habwt ydgments,emaaM apensn which mayN anywayamue AIRITANDLINCUNTT(T'O10,000CFW SUBTOTAL:
agalns,sal In en¢of the gnedng of this permit.
/-J
AIRFANDLINGUNrf(OVERIO,0(0CFM) CONSTRUCTION TAX
sign a Ad'paant/Contnna Da,e ExrlAusr EK)oo(w/Duca CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apned bYteune Aino occupant or haMk:havNou HF.ITWCUMT(TO 10,N0 BTU) Date Recet tM
material as deRned by the Cupertino MuNcipal Cod,Clupm 9.1;and the ��((��7j
HeakhaMSsfcty Code Sectbn75S37(a)r HEATING UNIT(OVER 1W,"BTU) TOTAL: iS63S
R
Y. ONO
Bl the applkantm tum Wilding occupant use equlpment maevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which rout hazardous W ree undua tssa deRiud by the Bay Area Air
QualnYe res ement Dista BOILER-COMP(7FIPOR 100,000 BTM
4 Ye °
Hvertadtheth& matae,S req lrementaunder Chaster. I of BOILER-coNr(OVER 1(A,000 BTU)
the U and Health[c lldln CM,S . 75505,75533 and 25531. I N 0 v 0 71990
uMmtand Nal lithe Wllding don nolcvrmntly hove stenant,that lcltmy NEW RE9DENTIAL MSCI-I. SQ.I7.
(restore@Iltythe Motthe mqulrtmenta which mush trct Rss��
P.to 'lta Cert ofOu pantyCiti
. Af h1nr �
Own rythmlud dgent Date
TOTAL ISS UED BY:
OFFICE COPY