21423 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemiflcallon PERMIT NO.
Building Address: Hoo-IC=;STF4D(P 21423
11hose: A A[' A
w"era sSTCR.tou]l CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
• �' ` "'
Architect/Engineer: BUILDING ELECTRICALPLUMBING-MECHANICAL CATEGORY CONI A�r
Lle.No: (n(��s b
QTY, ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PFRMITISSUANCE t (� ❑ ❑
LICENSED CONTRACTOR'S DBC RATION L�
Thereby af(irtn thatlam Bcensedunderprovsl sof Chapter9(rommeno- APPLIANCRSRFSTDENTIA DF RPI'ION D
ingwlth Se ton7000)of Divlslon3ofthe Busl d feadmaCoc1,.dmy - y
license Is In fullforce and effect PANELS
LicesenClyp Lk.
N
Date Vit Contractor
ARCHITECPS DECLARATION 201-1000 AMT'S
q�v ce Zp I understand my pleas shall be used as public records OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Fi X Licensed Professional SIGN LTO L _ p ED ' A`
6 c OWNER-BUILDER DECLARATION U lX'' N
0 owing reason. that[am exemptfromihe Contratorb Llmnselaw(a the �MAPUT ^ ^
70 O F.0 following reason.(Section 7071.5,Business and Profession.Code:Any city or OR E NST {I..�_ ,Ka
P49, c"untywhichrequimapermittoromtmd,alter,lmpmve,demolbh,orrepalr
O .a anyatm,ura prierlo its ssuance,aso requlresthe applicantfor such permit to ��,In
file a signed statement that he Is licensed pursuant to the provisions of the iN`�
7wj,A Contradori Literate Law(Chapter 9(commencingwith Section 7000)ofDWI-
p�0� sion3 of the Business and Profemlom Code)orthat he s exempt therefromand N I LELE C VALUATION
S" the bass for the alleged exemption. Any violation of Section 7071.5 by any
�« appBrantfor a permit subjetsthe applicant to a civil penalty of not more than T&SWTTC XTURES
five hundred dollars($500). NEW D � �
�n ❑I,as owner o!the property,or my employees with wages as their sole SQd'T-
compensation,will do the work and the structure he not intended or offered for
n sale(Sec.7044,Business and Profession Code:The Contrat.e.Lice.Law
S docs not apply to an owner of propertywho buildsor improvesthereon,and OC .
whodoessuch work himself orthreugh hisownemployees,provided that such C,GROf1P AESUNITS
Improvements are noHntended proffered fomale.If,however,the building or TOTAL:
Impmvemsnt sold wlthinoneyearofcompletiogtbe owner-bu[derwlllhave
t Nen of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEEFI.00 W7D APN
LJ L as owner of the property,am exclusively contracting with Ilmnsed pFRMTf ISSUANCE
con 1.0.to 0 the project(Sec.7044,B--!mak and Professlow Code:
The Contra Llcome Taw tloes rat apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wild.or Imprwea thereon,and who contracts for such pSojeta with a
co,1Bfat°r(s)Ilansed pursuantto the Contractor's Llanse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
OUTSIDE F
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPF 0
❑I hereby affirm that I have a certificate of consent to eelfdnwre,or a FIXTURES'PER TRAP SCHOOL TAX Y N
certifivteofWorkers'Comperuatl°nlmuranceaaartifkdcopythem(CFS . - RECEIPT#
3800,Led, S-GAS EA. EM-1 INCAOUILETS PA FEE Y N
Policy N RECEIPT M
Com n GAS EA.SYSTEM-OVER 4(FA) BUILDLNGDI VISION FEES
ertiied copy s hereby fumlahed.
❑Certified copy s filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLJA'�}1NCHEECC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID- "� CVr
COMPENSATION INSURANCE G
(This section need not Wcompleted if the permit s forone hundred dollars SEWER-SANITARY-STORM EA,20OFT. Date Recei t#
(51 W)orless.) ENERGY FEE Y_ N_
Inept employ
any peamuin any hewcokmanner so as to bco permitsseved, WATERHEATER W/VENT/ELECTR
I shall not employ any pers"a f any manner so m to become cob'ct to the
Workers'Compensation Laws of Callforns. Date R WATER SYSTEM/TRGTING
O Z Applicant PAID
Z O NOTICETOAPPLICANT:10ftermxkingths Certlfiate of Eemptlon,you NEW RESIDENTIAL PLMB. SQ,FT, Date Recel t#
rshould become subject to the Workers'Compensation provsloas of the Labor
N Code,you most forthwith comply with h provslom or this permit shall be TOTAL:
W > such
deemed revoked. "UBA
`E a
a p CONSTRUCTION LENDING AGENCY FEE '3ZIhereby affirm that there s A consttution lending agency forthe perform TOTAL: C FEEane of the work for which this permit s Word(Sec.3097,Civ.C.)O lander'BN.meG FEE14, I— LcndarsAddress 4TY. MECHANICAL PERMIT FEEO w mrtlythatlhave adlhsappBa onandaatelhattheabweinfomtion ICAL FEE1L scormt.lagreetocomplywithallcityand countyordlnancesandstatelaws PERMITISSUANCE ID:} N minting to building construction,and henebyaulhoturepresentativeaofths city to enter upon the aWw-mentioned property for Wpetion purposes. ALTERORADDTOMECH.(We)agree to save,indemnity an d keep harmlem the City of Cupealoo Receipt#agaWt liabilities,judgment.,.9...d expenses which may In any way accrueIt
DLING UNIT(TO 10,000 CFM) $U$TOTAL:.gal test City[ consequeresofthe ntiA oaths permit�� 8 ,� 9� DLNGUMT(OVERIO,000CFMI UCTION TAXS�oatwp6fApplianwContractor Data 'THOOD(W/DUCT) UCTION TAX PAID:HAZARDOUS MATFRIALSU SWill the applicant orfuture building occupant store or handle hazardousG UNIT(TO 100,000 BTU)rruterlalasdefinedbyth.CupeninoMunldpalCode,Chapter 9.12,and the RCCCI [#I iealthand Safety Cod,,Section2S532s)7 G UNIT(OVER 100,000 BTU) TOTAL:[ . Q
❑ Yes ❑No
Will the applicant orfuture building occupant use equipment or devicesTION FAN(SINGLE RESIU) ISSUANCE DATE
which emit harandous airrontandinanbas defined by the Bay Area AirQualityMamgcment Dlsbict7 COMP OII'OR 1!X),000 BTU)Ycs ❑❑Nhaveread ealthhe Safet Code,materiSe reonsre5ntsunderChaptr.1 ofOMP(OV�R l00,OfX)BTU)the Callfornla Flcalth k SafetyCode,Secti°as 25505,25533 and 25534.I understand that if thebuildingdoes not currently have a tenant.that Rs myIDENTIALMECH. SQ.FT �I,/i4 .f ln�a
respooddedity to notify the acv pant ofthe requirements which must be met M aG O0`x�,7
prior to issuance of a Certificate of Occopseq. _
Owner or authonud agent Data -.
TOTAL: ISSUED OY:
OFFICE COPY