21556 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PER.MITNO.
Building Address:15321556
5 McKKI l"I/tel jfaa�ra
wners amn. aq� one. p
1415 3641 CITY OF CUPERTINO-BUILDING DIVISION IZ� � tib
mr.cOrs Name: L .N¢ APPLICATION /PERMIT r L
I ^f r `r�Sa- BUfLDING-ELECTRICALPLUMBING-MFGHAMCAL CATEGORYCOMR�I-AIs-
Architect/Engineer. Lic.No: �rS
guyCN U b QTY ELECTRIC PERMIT r�FEE BUILDING PERMIT INFO
ress
Add : 'LG2 M as pa✓ PERMIT ISSUANCE ` (�
LICIIJB CONTRACTOR'S DCC RATION � • I�
Ihereby affirm that l am licensed under provisions of Chapter 9(commene APPLIANCES-RESIDENTIAL ]OB DFSCRI ON
ingwith Sedlon700D)of DlWsion3ofthe Buslneuand PmfemlonsC�e,andmy
Iimnrelsin full forcnand effed. .en PANELS Vy/ AJ
Lkenee Clauiep •rti�-p=�
Date_L ontraRor 9�_�yA�'(p(/GT,s,� 201-t 000 AMPS
UP TO 2DO AMPS
'ARCH ITECP DCCLARATION OVER IOOO AMPS SQ.FT.FLOOR AREA E/SQ.FT.
IqqI+��O7� Iundentand my plan dull be used as public rccordw 1
E Z Licensed Professional 9CN5 ELECTRICAL e 'r, I Iyt 0
<<�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MC5C -L l
7 F,�� I hercbyaffimathat l am exempt from the Contractor's License Law for the
po p following mason.(Section 7031.5,Business and Professions Code:Any city or P UTE R
O ZI"'u9 which requires permit to construct,alter,Improve,demolish,oree air TEMP.METER OR POLE INST. /
anysltyiucWreprWrtoite lwunce,also requlmtheappBanl(or such perMtlo
O�V file a signed statement that he Is lfceneed pursuant to the provisions of the POWER DEVICES
3w� Contractors Liceruelaw(Chapter9(commencing with Section 70M)of Owl- SWIMMING POOL ELECTRIC I ATE
O S sion3ofthe Buslnnaand ProfemiomCWe)orthathebexem therefromand AJaw
TI the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTVRES CT -)-9167
applicant for a permit subjects the applicant to a civil penalty of not more than I
five hundred dollars(5SM.
NEW RESIDENTIAL ELECTRSQ.FF. STORIES TYPECONSTRIICTIOh'
J ❑Lasowner 1 theproperty,ormyemployeewithwages r theledoor
G' compeneatlon,w111 do the work and lhestmtturebnm intended or offend for
psale(See.7044 Business and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilds or Improve thereon,and
OCC.GROUT' RIS.UNITS
who does suchwork himself or through hisown employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement Issold withinoneyearofcompleilomtM1e ner-bu8derw111 have
theq�urdcnofpruving that he did not build or improve forpurposeofsale.). QTY. PLUMBING PERMIT FEE
J FLOOD ZONE APN
I
Las owner of the property,(m.exclusively Busi contending with lisnxd PERMITISSUANCE '� CU _1
contractorsct covwctthe project(Sec.apply
to
and of
Cade.
The Contractor's License Law don not apply tct an owner of property who ALTER-DRAIN k VENT-WATER(EA)
bu0da or Improve thereon,and who contracts for such ptojects with a
m,�4stt(Tador(eexempt underPursuant Sm
the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec e k P C for this mason
OUTSIDE,FFfiS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT a
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP apt SCHOOLTAX Y N
❑I hereby affirm that 1 have o Insurance,
a c of consent to self-insum,(Sa C•C/ RECEB'f N
10 certiflab u(Workers'Compevationlvunnce ora certi(kd copythereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
polis lab CJ RECEIPT p
lla M GAS EA.SYSTEM-0VER d(EA)
CoCm any BUILDING DI VISION FE CS
❑pcertifled copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
[:]Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date RCmI t#�ZOtO�
(TMssectlooneed not becompletedifthepev tbforonehundreddollzrs
($100)or leu.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N—
I certify that In the performance of the work forwhIch this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING _
Workeri Comprmationlawsaf CaltfPAID
omia.Date
O Z Applicant NEW RESIDENTIAL PLMB. QFT. DatC Recd t# S Q OO
Z 0 NOTICETO APPLICANT:ILaher mating this Certificate of Exemptlon,you
H should become subject to the Workers''Com /.7
pensation provisions ofthe Labor TOTAL: 8ac
W Cod,you orintforthwith comply with such provisions milds peroatahallbe UI DIN --E It,L4
jdeemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE Za 0
d Z I hembyaffirenthat there is a construction lending agency for the perform- TOTAL asYt ELECTRIC FEE <�J
7 acts of the work which this permit b Issued(Sec.3097,Civ.C.) W
(-) 2
O Lenacr'a Name PLUMBING FEE
]anaera Adareda QTY. MECHANICAL PERMIT FEE -
LL U Imrtlfythatlhave read lhbapp8atlonaM statethat theabovelnformation �] MECHANICAL FEE
O w Iscorrect,Iagme to comply with all city and countyordinanssand nate laws PERMIT ISSUANCE t.. PEES PAID:
} N relating to building comtruction,and hereby authodre representative of this
F- city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMFCH.
Z Date Receipt#
(We)agree to save,Indemnify an d keep es which
the City of Cupertino
V against liabilities,pdgme ,costsand expenses wM1kh may In any wayacaTue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalnsts City in ns moe oft a n thl mut.
r •, AIR HANDLING UNIT(OVER t0,000CFM) CONSTRUCTION TAX ti
Igns Appl offillfb7 D e EXHAUST HOOD(W/DLICT) CONSTRUCTION TAX PAID:
HAZA R DOS MATERIALS DISCLO E
Will the a ppllcant orfuly re building ompant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Remi t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 5532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ye Mica
Wliltheapplicant or future building Occupant use equipment ordevices VENTILATION PAN(SINGLE RESID) I ISSUANCE DATE
which coat hazardous air contaminants as defined by the Bay Area Air
Quality Management Dktdcti BOILER-COMP pI'B'DR 100,000 BTU)
Yes No
have read the ha,caons materials requirements under Chapter 6.95 of BOILER-COMP(OVER IOU,"BTU) ���
the California Health k Safety Code,Sodium 75505,5533 and 25534. I 7
understand that lithe building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.PT. f
rrspmaibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Occupancy. �q
�yrys�
rizeTOTAL. {1/�,
Owner or authorized agent Date ISSUED B1
1, r
OFFICE COPY