21479 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building42c �8y I � nm F;� 21479
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rens antesn hone:
%�{,4RCW_ (- e., 7 -17/ /o CITY OF CUPERTINO-BUILDING DIVISION
Co attoreNap Lie.No: APPLICATION / PERMIT
F O BUILDING-ELECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROL
Architcet Engineer Lie.No:
a4�•�
�ny�' ♦ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:I OG94 S, D, YJIOC, PERMITIS5UANCE ❑ ❑ El
CONTRACFOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapler 9(commenc APPLIANCES-RESIDENTIAL JOB DESCRYIIION
Ingwith5 dIOn7000)0(DiWsion3olthe BuslnemandProlessionsCode,and my
license is In full force and dfect. PANELS
License Chas LIc.N _
Date Contractor —UP TO 2DOAMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
p Czz I understand my plans shall be used as pubbe records. OVEt1ODOAMPS SQ.IT.IdOORAREA S/SQ.Fr.
�(0 Licensed I'mfessimul SIGNS ELECTRICAL 7 — E ® Tkallt
Gnat OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC IDI V'
i., a I hereby affirm that l am exempt fromthe Contractor's License law for the
FZoo qqqqq�y following reason.(Eectlon 70315,Business and Professions Code:Anyeltyor t f'
9 countywhichrequimapermltlomnutrutt,dter,Impmve,dem Ush,orrepalr TEMP.METER ORIOLE INST. I I G
z 3 L 1
y�y an
pdissuance,uance,also requlrestheapp0mnt forsuch permit to POWER DEVICES
W Rte a signed statement that he h licensed pursuant to the provisions of the
3 u.� Contractor's License Law(Chapter 9(corrmuncing with Stolon 7000)of Dlvl- SWIMMING POOL ELECTRIC DA LIIATION.
�Op� sion3oftheBusinescand ProfesslonsCode)orthat heisesempt therefromand _
G the bass ifor the alleged exemption. Any violation of Section 7PELS by any OUTLETS-SWITCHES-FIXTURES
IFSEXIURES
applicant(ora permit subjects the applicant to a civil penalty of nd..the.
Ove1,asowner
of he pr, SQ.Fr, STORIES TYPE CONSTRUCTION
`�— ❑L hundred owner of the property,or my employees with wages a their sole al RESIDENTIAL ELECTR
compensation,w0l do the work and the structure Is not intended or offered for
Osale(Sec 7014 goal..and Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or Improves thereat:,and
F,3.. who doessuchwork himself orthmagh hisownemployess,provided that such OCC.CROUP RES UNITS
Improvements arc not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement bwldwithinomyearofcompleliogtheowner-buOderwRl have
thg burden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[as owner of the property,am exclusively contracting whh.tared ppRMIT ISSUANCE
contractors to mnvtmct the project(Sec.7044,Business and Professions Code:
The Contractors License Law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojem with a FEE SUMMARY
squats[orb)licensed pursuant to the Contractor.License Law. BAIX FLOW PROTECT.DEVICEL-i1 am exempt under Sec B k P C for this reawn
DRAINS FLOOR BOOP,AREA,GOND. SANITARY Y N
Owner Dns RECEIPT Y
WORKMAN COMPENSATION DECLARATION FIX,IVRES PER TRAP SCHOOL TAX Y_ N_
QI hereby affirm that I have•certificate of consent to self-h aure,ora RFOEO'r X
m0EcateC.Worken'Compensadon Insurance ora certified copy thereof(Sec. GAS
EA
GA INC41
OUT PARK FEE Y_ N
3500,Isis C.) RECEIPT S
Pox GAS- 4(EA)
Coim,any AS EA.SYSTEM- BUILDING DIVISION FEES
Certified copy is hereby te ty
Certllied copy h(fled withh the city inspection division, GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECICFEE
CERTIHC)ITEOFD(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORM EA.2001rr. Date Recei t#
(rhi. a ionneednotbecompleted Ifthepermiti.foronehundreddollars
(5100)ori..) ENERGY FEE Y_ N
I certify that In the performance of the work forwhich this permit is issued, WATER HEATER W/VENT/EDD-TR —
I shall nm employ coy person la any runner w u io become wb*d to the
Workers'CompemaBon lawn of California.Date WATER SYSIEM/TREATING PAID
O Applicant - Date Remi t#
2 this NEW RESIDENTIAL PLMB. SQbT.
Z0
NOTICE esubjettothe afierunkingperationlateof Exemption,YOU
should become subject to the Worker'Camperoatlon provisions of the Labor TOTAL '
N Code,you nowt forthwith mmply with such provisium orthis perrndt shall be BUILDING
W 7 deemed revoked. -
O. C CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
I hereby affirm that there 6.mmtmction lending agency for the perform ELECTRIC FEE
= Z ance of the workfor which this permit h Wued(Sec.309],CIv.C.) TA .
C1 O Lender.Name PLUMBING FEE
LL F Lender.Addreaa QTY. MECHANICAL PER IT FEE MECHANICAL FEE
I certilythat l have readlhls appllatlonand tlatethatthe above infonrstlon
O W
6 incorrect.l agereto comply with all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
>. W relating tobuilding construction,and hereby autho ee representatives ofthis -
" F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
_ (We)agree to save,Indemnify an d keep baroness the City cl Cupertino
aSabot li ,wdgments,coYsa pemeswhichmayleanywayacaue, AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ace adCi con once gra ngofthh IL AIR HANDLING UNIT(OVER 10,00BCRd): CONSTRUCTION TAX
Srf Appllan/Con tlor ^ Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building occupant store or handle hazardous HEATING UNIT 100,000 BTU) Date RCCeI e#
serial as defined by the Cupertino Municipal Coda,Chapter 9AZ and the -
HealthandSafety Cade Section 25531(a)? HEATING UNIT(OVER 100,000 BTU) TOTA �'
❑Ye. No
Wi111hexppllantaQnam
building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) - ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air
ality Management District? BOILER-COMP OHP OR 100,000 BTU)
t��f Yes read the haza❑No
�I 1Mve rdous materials requirements under Chapter 6.95 of BOILE(COMP(OVER 100,000 BTU) pp pp��
the California HealthA,Safety Code,Sections 25505,25533 and 25534.1 A
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility Issuance not Corti is to of cof eu pa nequlrcmenls whIsla must be met SEp _ 8 .
psponsiityto notify
thecateofOmhe req SEP.— (s\�\s`SY.jJ/iw7
l
Owner or aulhorieed agent Data _ ISSUEDBY: CLY J .
TOTAL:
OFFICE COPY