21344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruett Identification PERMIT No
Building Address:
g _�s s T �3 21344
Phone A A A
;1Zy/P 1te-7--5V7e CITY OF CUPERTINO-BUILDING DIVISION
• G°""'"° '"a"e1 Lie.No: APPLICATION /PERMIT
O G'GaXG /�JO/Jnt o�C'S—r09 BUILDINGdECTRICALPLUMBING-MECH LAICAL CATEGORY CONTROL#
Architect/Engineer. Lic.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
nacres: t
PERMIT ISSUANCE ❑ ❑ t ,l❑
LICENSED CONTR under provisions
1 MhSecioreby rn 7Dthatfam Bcensed 3ofthe ugne andPmCsions ode, and c APPI]ANCESRESIDEMiAL JOB DESCRQ'lION
Ingwith Sedlon 70r0�0F)offAWelon3o(the Buslneaand l'ro/esslonsCode,and my �I
li¢n�sin/�C11JJJJi correct PA - /)14#&45 K6p1giaF
Lien in fu - Lit# e2GSSO4 f
Date Contractor q 4' ,{ (1 1
ARCHITECTS DECLARATION 20t10D0 AMPS
]d I understand my plans shall be used as public records. J OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
Licensed Profealoml SIGNS ELECTRICAL
G c OWNER-BUILDER DECLARATION a
t. j Iherchyaffirmthatlamgx ptfromtlie Cr?ntrador'e License law for the �SPP.CIAL CIRCNT/MISC
70Z � lolWwing reason.(Section 701i,'Buslnm and l'rofeaione Cade;Anysclry ar.a�I TEMP.METER OR POLE INST.
FM ' countywhichrequbesap� mruttud,alter,improve,demo`Bsh!arrepair
q �.s anystrudurepdorl.Ilse Lisuanctdq also requirestheappliArtfmauchpermitto POWER DEVICES
Eep55�O 4 file a signed statement Ih(atC M ATC
sed pursuant m the p`rovlslo es of the
Q3 C Contractors License law haps ria commencing with Bgkm 7WO)o(Divi- SWIMMING POOL ELECTRIC
t,f50.g slon3ofthe Bn
uslnsand ProfsniosuCode)orthal helsQempttherefromand VALUATION
the basisfor the alleged exemptlen!I Any violation of Section 701.5 by any
i1�00 .Pphcantfor a permit subjenathe applicant to a civil penalty of not more than OUTLE'ISSWITCHESFIXTURESVO
qq live hundred dollars($500). ( NEW RESIDEMFAL ELECTA avv
01,a s owner of the property,or my employees with wages n she a e'QI'T SI'ORIFS TYPE CONSMUC1'ION
5t CmpenmHon,whldessand rinesshesltudurele noHnten dosoffcrad
` O sale(Sec. pply Bu sinessandf property
Solo TMCoci� ntra asLlaema'Ca
�$$ does not apply to an owner o(property atrho huills orimp estheieoRvand
whodocasuchworkhlmselr orthiL ghhhh`•hh����p��Gsssssowne��QQpes,p idedfhatsuch OCC.GROUT' RFS.IRYITS
improvements not lntendo�o(fer (or�ale.al( owev ,thebullaing or TOTAL:
Improvement LssoldwlthI.. yearotc plelioo,theowne W .rwilihave
tnrkurdenofpmell nglMtM rd notbuldorbnprovetorpurposeo(sale.). QTY. _ PLUMBING PERMIT FEE
LL_J S as owner of the property,am exclusively contracting with licensed FT.00D ZONE APN
contract°ratoenstect the project(Sec.7094 Buslneaand I'mfessimes Code: PERMIT ISSUANCE
TM Contractor's License Law don not apply to an owner of property who ALTER
buhde or improves [Person, and who contracts
for such plojects with a DRAIN&VENT-WATER(EA)
off, o more t under ant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am eacmpt under Sen B k P C for this mason
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
• PQl hereby affirm that I have a cortificate of consent to self-insure,ce a FIXTURES PER TRAPSCHOOL TAX Y N
certl(Icate of Worken'Compematlmlnsurane ea enl(ied copythereof(Esc. RECEIPT#
380,Labe �� o GAS EA.SYSTEM-1 LNC#OUTLETS PARK FEE Y_ N_
Poii y# WIiA �o7p �3
GAS FA.SYSTEM.OVER#(EA) RECEIPT#
Com any O QIs he H77I'/! BUILDING DIVISION FEES
Certified copy Is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Ce Ifled copy isfiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Dissection naednot becompleted lithe permit isforonchuromd dollars SEWERSA ITARY-STORM F.A.20OFT. Date Reeeipt#
($100)or lea.)
Icertify that in the performance ofthe work for which this pemdt is Wvrd, WATFRHEATFRW/VENT/Ff TR ENERGY FEE Y_ N—
I shah not employ any person in any manner so n to become subject to the
Workers'Compensation Laws of Calilomia.Date WATER SYSIFM/TREATING PAID
O Z Applicant
_Z O NOTICETO APPLICANT.If,after Auking thCvCertlflrm of Exemption,you NEW RESIDENTIAL PLMB. SQ,FT. Date Remi t#
should became subject to the Workers'Compensation provisions.(the Labor TOTAL:
~ W Code,you most forthwith comply with such proNelons orthts permit shall be LU > deemed revoked. BUILDING FEE C10
CL CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
= Z eof the af(Imnthw there bacomwesgued(Sec. agency(.C.) perform- TOTAL: ELECTRIC FEE
ante of the work(or which this permit V WUN(Sec,3097,Civ.CJ
U O 4naers Name PLUMBING FEE
U. Lenders Add— QTY. MECHANICAL PERMIT FEE
OLU ]enitythatlhave read thisapphatlonand tatethattheabove Information MECHANICAL FEE
0. dconuct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEESPAIU
r N relating to building corutmdio",a"d Mrebyauthor mpreanlativnofthis
Z city to enter upon the abovc�mentloned property for inspection purEN
ALTLRORADDTOMECH.
V — (We)agree to ave,indemnify an d keep harmless the City of Cin, Date Receipt#
ttliabilities,judgments,marts. e.penses whichmayinanywrue AIR HANDLING UNIT(TO 10,000 CFM)id ty In mor granting o(this permit. SUBTOTAL:
MRHANDWNGUNIT(OVFRIQWOCFM) CONSTRUCTIONTAX
DateEXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant orfutem building oavpant store or handle haus HEATING UNIT(TO 10,000 BranmalenalasdefinedbytheCupertinoMunldpalCode,Chapter9.1$ e DateRecei t#
HealthandSalctyCad`,Ssctloon25537(x)7 HEATING UMT(OVER 10,00 BTU) TOTAL:Yn 1rY�aT+n. tWill thezppllcama luturc building occupant use equlprrcnt ors VEMDLAnON PAN(SINGLE RESID) ISSUANCE DATE
which emit hamodous air contamimnhas defined by the Bay Area CQualityMawgement 'st u 7 BOILER-COMP OHP OR 10,000 BTU) ` t'uYcs No4Mve read theh r snuterlals rcqulrerrcntsunder Chapterf BOILER-COMP(OVER10,000 BTU) 1o4Ui590
theCalitomlaHealth SafetyCode,Sedlons25505,25533and25539unde tandthat if the bulldingdce notetlhy NEW RW ENTIAL MECH. SQFGibility to not lfytbemPaul of he requircmenis which musetp r La raceo(aCenif a f0 anry. CIly of ftvdt1?fhBA Y
Owner of authorlud ai Date
TOTAL: ISSUED BY:
OFFICE COPY