21509 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Rapidan era ed Idendffadmr PERMIT NO.
0ulding Add nv: (.IO S sI L, CLl l,�Dl� 21 509
sera ante: me:
- SON 25 — otQV CITY OF CUPERTINO-BUILDING DIVISION o^
Contractor's Name: Lk.No: APPLICATION / PERMITT W
15
BUILDINIr ECTTUCAL.F U lNG FUMCAL CATEGORY CONTROL X
Arrhxnct/Gglreer: Llc,No.
QTY ELECTRICPERMIT FEE. BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ El ❑
LICENSED CONTPI uC er SDECLARATION
I hereby affirm that pat l.3.furderprwW.pm Chvpler9(.comm APPiJANCESRESIDENTIAL
B DF_SCRO'Tf0
mewl,is inion force a Dlvielon3oflheBuWemmdPminstauCode,cool
Liner.lnts fora and dfea PANELS
LI¢nx Clsn Llca r
Date Cr
ARCHITECT'S DECLARATION 101MPSOVERIOOOAMPS IFA
¢O ZCO I underataM n'Y pW.SIuB be used n public reaada �.FT.FLOOR AREA f/�.FT.
L`kj� Licensed Pmf.io.l SIGNSELKMCAL
< IhembyafflrmthaOWNER-BUILDER DECLARATION mev rAL CIItCiITT/M6C
Ztlamexempfmmthe CommMoor's Lkeruelewfmthe
Opi.� follow[ngma .5miw7m15.BualneaaMPmfmbna Cade Anydtyor TIO.MEER OR IDLE INST. �
F� c ntywhlchrNubeeaper toco.trud,alter,lmpmo demolbh,orrelWr Q
�t a vnyst.cturtpMrolta lsararce,vLsorryuire,iheappBantfm wch.smolt to POWER DEVICES
0 U file•ngned mtement that he b 1ke.M Puntunt to the pm,,abro of the
Owl_ Contractor's License law(Chapter 9(mmmenMg wW Section MOD)of DM.
ebn3ofthe Budn.and Pm(mbru C.de)orNm heetexempttherehomand SWIMMING POOL EUCIRIC VALUATION
the basis for the alleged evemptbn. Any violation of Section MIS by any
appBont kra permit subkas the applicant toa dull penalty of oct more than OIITLETSZW1TCHES-FIX7IIRES
five hundred dollars(SM.
'9..' 01,as owner of the property,or my employee,with wages as their anis NEW RESIDENTIAL ELECTR SQYI'. STORIES TYPECONSLRIICTION
C 6 pe.anon,willdothe work and the simcturt brat Blended or offeredfor
S O .dile(Sec 7066, stre and P.fmbro Code:Tie e Game law
s$ d w pplyto pp y lsldarmpmn ue nd
woda hrkhifatmhhlo pWdttoch
OCC.GOUP RES.UNITS
ImprovemnsamnntenddoroffenfmmLe.IfIx.eve,thebildingor
TOTTAL:Dal
Improverrcm bedd vAhln orcy.rofcompinbn,theavner-bullderwBl have
ttlflf.+rden of proving Nat he did rot baud orlmpmve fa purpme.tens.). Q7y, PLUMBING PERMIT FEE p DZONE APNr
LI L as owner of the property,am eehulvely contracting with licensed
omlranon to mrutruct the project(Sec.7066,Buelnm and Pro(mb.Cade: PERMIT ISSUANCE
The Contador'a License Lw does eta apply to an owner d property who ALTER-DRAW&VENT WATER(EM
or Imp.thereon, and who --.Mfor Ids ptn"with a
cQIl�acta(e)IkenSed pursuant to the C.ntnctda Line.Law. FEE SUMMARY
U I en exempt order Sec B&P C for this reason BACK FLAW PROTFY_T.DEVICE OUTSIDF
DRAINS-FLOOR RODF,AREA,COND. SANITARY Y_ N_
Owner Date RFLmrT X
WORKMAN COMPENSATION DECLARATION
❑1 hereby aHlron that 1 have•certificate of content to sell-twn,or Fl)nIJRES PER TRAP SGT 1001.TAX RgE7PT X
Lab C.)
aminate of Workers'Canperoatlonl.uranama¢dllfed copy thereof 03ee- GAS EA.SYSTEM-i BJG60UTLEIS PARK FEE Y_ N
3800,
Policy Y RECEIPT GAS E.A.SYSTQ.1-0VEA{(EA)Pum nY BUILDING DIVISION FEES
Ceb hereby furnished.
Cea fled copy llied mpybflled with the dtyl.pectbn dlviston. GREASE/WDUSIRL WASIEINTFRCFP'IOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRU' PAID
COMPENSATION INSURANCE SEY✓ER-SANITARY STORM FA 3TOFT Date Recei t#
(TMssectbn need not be eomplmed Him permit b to ane hundred doBan
RI II mmfy that
WATER HEATER W/VENT/EFLTR ENERGYFEE Y N
lunare employ
any
nhe y person In anye of mhe anner
sorwNohcomthfit ermltlslto the
I shall nae employ any.Lawn f any runner m u to become abject to the
WATER SYSTEM/TREATING
O Applicant
ompenvlbn lawn vl GB/ornb. Date PAID
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEWRESIDFNIIALPLMB. SQ.T. Date Reed t#
Should become Subject to the Worten'CooWe.tbn provbio.of the labor TOTAL
~ N Code,you v f nthwkh comply with such proviso. rthis permit dull be
> deemed tewked. BUILDING
Lu
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercbyaffl m thetther,Waco.t.dtm iendmgageocy for the perform ELECTRIC FEE
7 Z anaaftheworkforwhchthb pemdtbbmud(Sec 30D7,CN.C.) Tm'AL
O Larder.NamePLUMBINC FEE
LLF Lerderb Addrm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Lad By that l have read this application.nd state that the above lnformani.n
bcon-t.I agree to comply with W city and county ordirunacn and state laws PERMIT ISSUANCE FEES PAID'.
>. 0. relating to balding mrstrunbn,and herebyenhoere repreematives of this
F Z city to enter upon the aboa-mentio.d property for lvpectbn purposes. ALTFRORADDTOMFCH. Date Recei [#
— (We)agree to ave,bdcmNfy an d kapardw
h .the City of Cu pertl
aga Bret habWlles,)adgmemn,assts and expenses which may In any way amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal.t Said City in ra of the gaming d this permit.
AIR HANDLING UNIT(OVER I0,0X)CFM) CONSTRUCTION TAX
Signeure oFAPP0ffnT7Cmfrems Date E)GAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oav pant atone.,hand le haaardoua HEATING UNIT(TO 100,000 BTU) Date Recef t#
materiel e,defined by the Cupenino N
Mucipal Code,Chapter 9.17,and the
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
I—I Ye, Q No
Wthe appllam m�WreballdingoceupantuxeclWpmertadMus VENTILATION FAN(SINGLE RFSID) I ¢DATE
which emit lunrdo.air contamiruma as defined by the Bay Area Air OW
Ixy Management District? BORER{OMP PHP OR I00,0M BTU)
Q�I
Yn No
• • Shave read theb roue materials requirements underChapler 6.95 of BOILER-COMP(OVER 100,ODO BTU) /YCCa ��QaC'll
the Calilomla Health&Safety Code,Sectio.25505,YM3 and 25536.I OACV ,xsw'
udentandi that if the banding doe,not corrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQJT ,
responsibility to ofa(the cats of oftherequlremema which,mut berM
primtobsuancc ofay the ate ofd of the
uy.
O.vncr ce authorised age. Date TOTAL ISSUED BY:
-
OFFICE COPY