23081 APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES = USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Add mea:
g8z F�tnA ST" . 23081
Knen one p
9 VIA QI kf-21)F_F_ S7728i,56-0 CITYOFCUPERTINO-BUILDING DIVISION
c°"° does on":
Lle•No: APPLICATION / PERMIT Z
.
Archi /En carBUILDINGELECTRTCALPLUMBINGMFGHAMCAL CATEGORY C
tap& �M5 i �°) OL
QTY. ELECTJitC PE IT PGG BUILDING PERMIT INFO
Addrcsa: (ED IuFV S�1 PERMITISSUANCB OP SP
LICENSED CONTRACTOR'S DECLARATION
Ther by Sectio 70 than am Bcensedheunder Business
annsofChapher ssions9(commeno- APPflANCFS NTIAL OB DFSC N
in ease 1 Section 7000o(d Division afthe Buslneasand Pco/eeeloneCode,and my license
la In ful{{//o��rce and died. P
Lima.Class�Llc.p S01 X
Date Contract° tC.{�. igeuva
ARCHI S DECLARATION "ELECTVC
�� •• V
O Z I unci d m used es public records. - - SQ.FT• 00 AREA :S/SQ.FL
p� O r r
rofenla.l s
PSIGNSA Z 3 f'G\I 2-s 3
Q OWNER-BUILDER DECLARATION0
2 1n a SPECIALCIR T/MISC 1 ` �t-7\f
e .
L., Horebyaffireathatlamexemptfrom tha Contracars -foensehwforthe
pp followingresson.(5e i=7031.5!u':io .and Profemions Code:An ct or 1 a d
y ty TEMP. OR POLE INST. 7rr— '�wDa o2.( •
�,4 cwntmenummqulrna Issuance,
to also requircathe
uircathe apmvgdennlbh,°rrepao
anyatmtlurcpdortoltehat toil alsopursuant t t hefor isions of to POWER DEVICES O Z(1a s
0 � ContBlera signed Mcens enotLa Nat ha t r9(exalicensed pursuant to theictio. o.of the
Ow Contractor's Business
and Proapier9(com rothin eihSxelcmtpt �) t I-
�O she basis for
the alleedexempvbn. Any violation
not Section
�� SWAShRNC POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any vlolatlon of SORIon YYYQfh app
Q5 applicant for a permit subjects the applicant to a civil penalty of cats _ F l/ I
�� flue hundred dollars($500. ��,�� NEW RESIDPN7R
�n I,as owner of the property, &&& .'e`Q�' STORIES TYPE CONSTRUCTION
p Felly,or my employees with wage lh of
� compensation,will dothework and thestmcturebnet l tended or offend for
�pa sale(Sec.7041,Buelneu and l'rofesslo.Cade:7hc Co ractofa l/>bpfL•{aw
does not apply to an owner o(pmpertywho Wilds art est c��l�l hhnn ___60C GROUP RFS UNITS
C• who doeasuchworkhimselforthrough hieown employees,pmv caid.t.ch
Improvement are not Intended oroffered forule.IL howeveq the building' a
Improvement t sold wllhln okyearofc°mpletlon,lhnowner-builder will have
ll,, rdenofpmvingthathedld.a Odorlmpmveforpurpouofule.). QTY, - PLUMBING PERMIT FEE
U L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to construct the project(Sac.70M Busmen and Prefrnio.Code: PERMUISSUANCE �
The Contractors License Law don not apply to as owner d property who ALTER-DRAIN&VENT-WATER IEA)
Wilds or Improves thereon, and who contracts for such En ainets with a
cgpkactor(s)Iimneed punuant to the Coremoo/s License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1 am exempt under Sec B& P C for this noon
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner - Date AECAQ'T,N
WORKMAN COMPENSATION DECLARATION' FIXTURES-PER TRAP SCHOOLTA% Y N
QI hereby efflnn that I have a nrtifiut of consem m Belt-Inmre,ora ^- �� RECEE'T M
cenlflcateof Wurken'Compe.atlon Luvnm oracertlfled copylhereo((Sec. GAS G.SYSTEM-i INCAOUTLETS �� PARK IEE Y N
3800,1..6 C.) n
Policy N GAS EA.SYSTEM-OVER 4(EA) RECEIPT#
Com any BUILDING DIVISION FEES
' Certified copy is hereby furnished. GREASE WASTE INTERCEPTOR PLANCHECK FEE
Ccrtlfied copy t filed with the city inspection division. 60
GREASERRAP G�j
CERTIEGMPENS TIONINFROM WORKERS' PAID 14— (
Cm b core
COMPENSATION INSURANCE SEWER-SANTTARY SEURM EA 200FT' Date Rixel til
(ThteMlon random W rompleled If the permit t(canons hundred dollars
(t101))orlcse.) WATER HEATER W/Vpxr/E- ENERGYFEE Y N
I camly that In the pedomsneeof the work forwMch this permit b lswed, Ec7R V
I shall not employ any person in any manner n act to become subject to the WATER SYSTEM/TREATING
Woloorecompenution Lawsot Calffmala. Date PAID (L�7-�f/ �D d—•
ZZ I Applicant
TO APPLICANT.If,after making this Certificate ofFemptlon,you NEW RESIDENTIAL PENH. SQ.FT. Date Recei to
HO should become subject to the Woricers'Compe.ation provtW.of the Labor TOTAL: 1IL4 3,0
N Code,you must forthwith comply withsuch Envtio.orthls p.motehallW
ILI D. deemed revoked. I BUILDING FTE
CONSTRUCTION LENDING AGENCY SEISMIC FEE _
Il IhercbyaErm that there to construction lending agency fur the perforro- - ELECTRIC FEE
Z once of the woritfor which this permit is Issued(Sec.3097,Cle.C.)' - TO
U O' lander.Name - PLUMBING FEE
LL H Landers Addrcas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE '
OW lrndi(ythatlhavcreadihbappBmlbnandetatethat Neabove lnforrwtlon
1 Is comect..I agree to complywith all city and county ordleancesand Mate laws PERMIT ISSUANCE FEES PnID:
} N relating to building construction,and heneyauthotl mpresentativesoftht 1 _
city to enter upon the above-mentiod propertyforiespeatlon purposes, l ALTERORADDTO MECH. EYe1Pt11
V — (We)agree to save,indemaily an d keep harmless the City of Cu pertlno
against liabilities,judgments,colla and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SU TOTAL: VAxj CT
ag.trat suevoyincon a the granting of this permit. ,s
(7-, AIR HANDWNG UNIT(OVER 10,"CFM) CONSTRUCTION TAX
t of AppRont Co actDate - D(RAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or filen building occupantemramhandle hazardous HEATING UMTHO 100,000 BTU) - Date Ree ' tie
r. material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
Ilealthand Safety Code Section 75532(a)P HEATING UNIT(OVER t00,000 BTU) TOT .•
❑ Yes M N°' I
Will the applicant orfuturebuilding occupant use equipment or devices VFNTILATIONFAN(SINGLERDSID) ISSUANCEDATE
which emit haeardoes air contaminants as defined by the Bay Area Air
Quality Management District? " BOR,ER-COMPOFE'OR100,0fDBTU) -
qYcs No p
havenadlheh.a ou6 ma terialsmquimmentM
PAID
underChapter6.95of BOILER-COMP 100,000 B
the
California I Inith&Safety Code,Sectio.75505,25533 and 75534. I ' P A B
understand that l(Nf the occupant
note requirmnts hichLthat it is my ` NDV✓RFSIDENTIAL M[iCFi. SQFT
responsibility notiflithe the done of nor currently
has which thatWmet TIAL CJE '
prior to issuance of a Certificate of Occupancy. 1/f�yL iia J 0.3
UN e A
ll
Owncrminithorlmd agent Data
11)) s t7
ISSUEE9BY:
OFFICE COPY