21058 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed Identification PEILwTNO.
Building Addms.:
216 $S Grana�c� �� 21058
S one.
nE CITY OPPLIC TINO-BUILDING DIVISION
Ca,tndare Na Lac Nm APPLICATION / PERMIT l LSA
D f BUIDINGnM7RKAL-PLUMBING.MWHAMCAL CATEGORY CONTROL/�
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Add-702 G: IR•RAUTISSUANCE ,DV 4��i
LIm that ED CONTRACTORS DECLARATIO Lit
Thereby
affirmthatice maedunder heBusi vbloruoffiese-9(®nmen APPI]ANCESIlF4DFMIAl JOBD
Inurso is inft?S _af DlvWon3o(theausircss dProfeesloruCode,and
harass Is In s anti d 0 C% PANES
Dau Gla Costa Vf J
Dale Condrattor
ANTS
ARCHITECT'S DECLARATION 701-1000 AMPS
�2 Iurdermand my plaruehaB be used a public record. OVER TOW AMPS SQ.Fr.FLOOR AREA $/SQ.FT. '
IIyy O
Licensed Pmfessbnal SIGNSELFLTRICAL
L
6c, OWNER-BUILDER DECLARATION Sp2CIALCIRCLTF/MISS .
yl"'eYA7 tS^ 1 herebyaffi.that l en em pt from the Contractor'.License law for the
pp falbwing rtaeon.(SeRIm 7m1S,Buslr�ard l'mlealone Code:Any dry or .
6'7.1- TEMP.MEIIOt OR POLE INST. -
PEG anystm mpm taap ame,arorequ,dttheaprvso,dfmo &,orrepdr
any assigned pd statement
art he Is abmsec!pursuant t the fmrwchpemdt a POWER DEVICES
r5 file a signed Wtement slut M b Iloensed pursuant to the provIsloru of the
0 uu.r Contratlorb License Law(Chapter9(commencing wdh Section 7000)of Divi- SWIMMING POOL ELECTRIC
FS
of an 3 of Ne Business,and Prdssv
obCade)outlast he Isac
empt thermfromVALUATION
ard _ G
..•]]]] elthe yeb for the alleged enemptlon. Any violation of Section 70315 by any OIJTLE
p eppBunt fora pemdt wbj 1.the applicant toatlWl pevNy door moat than ✓ c"�NRFS b
fiveshundred dollars0$5=. NEW RESIDENTIAL ELECIR s• •Jl
F,�n U I,as,owrcr of the property,or my employes wtth wages as their sole �'�. STORIES TYPE CONSTRUCTION
G' compensation,wBldotk work,and thepwcture,It wt Intended or offered for
d.,J p role(Sec.apply Busby-as 1 of property
who
build.
The.1 impr ols lJmve law -
rj�$ whorl t applytorkan o lfe property sownedsorlmprovnt thatcon,and OCC.GROUP RFS UNTTS
0.0. Improve wch am W Intendedowghldsownemp,hot,epwvWedilding h
Impmvcme.eatelwtlntended ear.fredfatIon,thihowevcr,thebuilding TOTAL 3 ,00 .-
Imp verrrru bsoW wBhln oneyurmfcanplelbr,rhe ownmbuilderwW five '
t raof proving that he did not build or Improvepurpose of for purpof sale.). QTy. PLUMBING PERMIT. FEE '
Um 1,e sonnet of the property,am e. hurvey�tracting with licensed FLOOD ZONE APN
contractor to mntruct the project(See,70K Business and Pofeebro Code: PERMITISSUANCE �, Vb
The Codratlori Licerue e Law donor apply b an owner of property who ALTER-DRAIN&VENT-WATER CEA)
WIIds or imp.thecontracontractsw
thereon,and who contracts for such plojecta h • FEE SUMMARY
cyllp. .10)Bmued purwant to the Contractor'.License law. BACK FLAW PROTECT.DEVICE
LJ I en ummpt uodn Sec B&P C for this reason -
Prrq
DRAINSFLOOR,ROOF,AREA,GOND. SANITARY Y_ N
Owner Date RECEB'rI
WORKMAN COMPENSATION DECLARATION FDCNRES PER TRAP 0 SCIiOOL TAX Y_ N_
❑1 herely oink that I have•ceM(bte of current d apythrurt,ora RFLEPr h
MW,L&1eofWor4en'CwnperwUmtivunnce cera certified mpythe�co((Sec. CAS E.A.SY51'E7 IINC4 OUTLETS PARK FEES Y_ N_
3gOQ ab CJ
Cph', CAS EA.SYS OVER4(EA) DING DIOT VISION
�CFry BUILDING DI V ISION FI:FS
Certified copy herebfiledyfumbhed. CREASE/INDUSIw.WASTE INTI2CErmR PLANCHECK FEE
edified copy 1.(Tied wlthtM city Inspection dfvidon.
CERTIFICATE OF O(EMPr10N FROM WORKERS GRFASET'RAP PAID o
COMPomplet ed ONINSURANCE SEWFR-SANUARYSTORM FA 200FT Date Recd tH OI LSD
Ohia.edlmnneed not be cro SATu the pormiSURA b fm ora hundred dollu.
(510()orless') WATERHATER W/VINr/ELCI"R ENERGY FEE Y N
I mnifythe N tha performuna of the work for which thdaed
is permit is b ,
I.hall not employ any person In any manner w as to became subject to the
OWATER SYSIPM/IRFA77KG
Waken Compensatbnlaw.ofUWornia. Date PAID—
Z.'Z NOTICE NEWRESIDENTLM.PLMB. 90Ff. Date Remi til J"s
Z O
NOTICE APPLICANT:If,after coking thisCertificate of Eaemptbn,you
.hand become sulapd to the WmI en'Cmmpera.tlnn provisions of the Labor TO
N Codgyou.9ficrthwghconply with such proviMmnmorthh permb shall be p
domed revoked. O
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE .Z
a Iberebyefirmthat there Is a construction lending agency fmrthe perfomf TOTAL ELECTRIC FEE ,p
7 Z once of the workfor whkh thio permit Is Issued(Sec 30g/,Civ.C.) -DO
02 l<ider.Name PLUMBING FEE
LL Undar.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ,p
O W 1 onAilythe l have mad this application and sterthat theabmm
velnfoation
11 lemma..Iagreeto comp) naBCtyandcountyordbunoeamd datelaws PERMIT IS U( CE. ,Z,Oo FEESPAID:
�. relatingto WlkBng mrut Ian,mulherebyeaho ummprecntelveofthb
= dry W r.mruponthe mentis property for inspection purposes. ALTERORADDTOMECH. -
we to save, mdy an a keep harmless the City of Cupertino Date RCCCI t#
V .g.i Iia Wiles, ,codaaMe,p mesw msylnanyway. cue AUIHANDL.INGUNITODIOADOCFM) SUBTOTAL: 6
ag.i sat CByin the granting dthl.permit.
AIR HANDLING UNIT(OVER 1Q(=CFM) CONSTRUCTIONTAX
X Signature of Aant/ ontracta Date E(HAM HOOD(W/DUCE CONSTRUCTION TAX PAID:
HAzARDOUS MATERIALS DISCLOSURE
Will the applioM or future Wilding occupant store or handle havrdous HEATING UNIT 00 IOD,ODO BTU) —Date Rttef tit
rmaterlal as deBrud by the Cupertino Munitlpal Code,Chapter 9.17,and the
IL-.xh and Safety Codion 755.77(})? HEATING UNIT(OVER 100,000 BTI!) TOTAL:
❑ Ye No
WWthe applicant or futum Wilding uapaet utr equipment adevkn VEI'MLATK)N FAN(SINGLE RF9D) ISSUANCE DATE
whkh emit ha anent.air Dont.rr,rrums as defined by the Bay Area Ab
QualBy Mnvgercrd ,LBOII.FR-COMP PfB'OR 10o,IXq BTU) 1 . 00 PAY®
4 Y. No
Nve read the ous nutcrlab requlrtmenb under Chapter 6.95 of BOIL]:A-COMP(OVFR 100,W0 BlTn
the California Healh& fey Cade,Sections 25505,SS11 and 75534. 1 4G71 91 90
and rad that dNg doe.riot currently haveatan.nL that itbmy NEW R®DINIIAL MGQi. SQFr.
ro ns ility to notify eoavpart d the requirement,which most be Iter pj
pd to coned. Ifiatcof0¢vparuy. W of
44,
/� Owner nth • t to
TOTAL ISSUED BY:�jy(�e
/
OFFICE COPY