21603 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address e �Q-) - 2160310
3. 111 ;4 C'
wne arae: - one: TrrAT=
4•
I$, PD s, CITY OF CUPERTINO-BUILDING DIVISION "
Coocta aN ,S SLI` 'APPLICATION I PERMIT
n BUILDING- CATEGORY CONTROL if
Architect/Engineer. Lk.No: ELFGTRICALPLUMB(NGMECHAMCAL
C�l „(�A�� QTY ELECTRIC PERMIT FEE �RUILD,INC�PERMIT INFO "
Address 6 .Sid', 2 .
rERMIrIssUANCEi, - az t Ce�7 fdf .S ®.
LICENSED CONTRACTOR'S DECLARATION Apt>LIANCFSRE4DENI]AL DSI •'
I hereby affirm that lam Remsed under provlslons ofChapter9(commen 6aC� ]OH DESCRD'1'ION
Ing with Section 7000)of Dlvlslon3 ofthe Busloe_ssand ProfemlonsCode,and my n c jN
license lsinfafo andeffet LLA` PANELS ��1•I'(
l censeC m L. M.�J l ` '
Date Contactor - UVIUMIAMPSp- -
ARCHITECTSDECLARATION 101-IODOAMPS
q�q�vv NO� I understand my plans shall be used m public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.F7.
` k Licensed Professlovl SIGNS ELECTED •-
Q�4 OWNER-BUILDER DECLARATION SPECIALCDICOIT M .. I^` "" T—
EC
— J
,zs' � I hereby affirm t0h WUameaempt from the Contractm's License Lw for the 1
O .. following reason.(Section 7031S,Business and Professions Code:Any city or I '; 11 1', 1�( -
�"' munlywhichrequimsapermitwcomt d,dler,impro ,demollsh,arrepalr TEMP.METFR ORPOLE NSC.,. U I /II SJ
gg� anystrocture pdorto its hsuanee,also requiresthe appHcentfor such pereatta pp$ygg DEVICES i
0 file a signed statement that he I.Hmnsed pursuant to the provisions of,the _
uaM Contactor',License Law lChapter 9(commencing with Section 7000)of DM- SWIMMING POOL ECTRI
slon3ufthe Businessand Profemlom Code)orthathelsemmpttherefmmand - •-'—' VALUATION
PH< the basis for the alleged exemption. Any violation of Section 7031,5 by any OUTLRTSSWITCHE FIX7URE5 1 0.•eyv QQ 0 �a
appb"rat iota pemdtsubjects the applicant to a civil penalty oaf not more than l L4J J
five hundred dollars($503),($500). NEW RES5Q.FT. STORILS TYPE CONSTRUCTION
�n M I,as owner of the property,or my employe"with wages as their sole
mmpensation,will do the work and the structure is not intended or offered for
O rule(Sec.7064 Business and Prafembm Code:The Contracem's License Lw
does not apply to an owner of property who Wilda or improves thereon,and OCC.—GROUP RES.UNITS
whodoso suchwork himself or through hlsown employe",provided that such .
Improve rrentsarenctlntendedorofferedforsale.ILhowevegthebuilciingor TOTAL: s
improvement is sold within one yearofcompiedon,the owner-W gderwill have
tl)gEurdan of proving that he did not build or Improve for purpose of sale.). Q'jY, " PLUMEINGPERMIT . ,FEE, FE55DZDNE APN
u L as owner of the properly,am exclusively contracting with Ilmowd PERMIT ISSUANCE
contractors to construct the pmject(Sec.70K Business and Pramesions Code: � 11 CD
The Contractor's License Lw does not apply to an owner of property who ^ ALTER-DRAIN&VENT-WATER(EA)
Wilds or.Improves thereon, and'who contracts for such ptojects with a ` FEE SUMMARY
��RCaetmW licensed pursuant to the Contractor's License Law, gAQ((pLO$y pROTFOT.DEVICE'
t_]I em exempt under See. B&P C for this reason
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
M Owner Data RECEIPT K
WORKMAN COMPENSATION DECLARATION !L pIX.I.URFS PER TRAP QO SCHOOL TAX Y N
❑I hereby affirm that I have a certlfirate of consent to eel(-insure,ora J RF.�mxC p
3800tiLb Ct Workers''Comper Umlraumnmoramrtifled mpythereof(Sec. 1 GAS EA,SYSTEM-1 INCA OUTLETS � s� PARK FEE Y N
Pdiry x l RECEPT if
GAS EA.SYSITM-OVER 4(EA)
Com
an
BUILDING DIVISION FEES -
�CertlfiedropylsfierebyfuM ed. - - CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE -
ICertlfied copy ls(tied with the city Inspection dlvlelon. ,
eKK CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP PAID
COMPENSATION INSURANCE SEWER- STORM-yTORM EA pOFf. Date Recei t7F
Uhlssection need nor be completed If the permit is for one hundmd dollars
($]Iorlme. WATER HEATER W/VENT/ELECTR e1j2,Ca] ENERGY FEE Y N
I "
cert yth) in Performance for this permit is issued,
1 shall note toy any pereon In any manner so m to em subject to the WATER SYSTEM/TREATING
117.E/.I.REA.I.ING
Zola,.Co��pppp�1¢¢ppenmtlon of California.Dace 1 I PAID
O Applies. l»aPLI' k161�
Z NEW RESIDENTIAL PLMIL SQ.FT. Date Recei ti
Z O NOUCE TO APPLI .I,after making this Certillate of Exemption,you
should become subject to the WorkerCompensation provisions of the Labor TOTAL:
Cr N Code,you at forthwith comply with such provisions or this permit shall be
W y deemed revoked. : BUILDING FEE
a O CONSTRUCTION LENDING AGENCY,• -, SEISMIC FEE - I
ZIherebyafflrmthat there is a construction lendingagency for the perform- TOTAL: ELECTRICFEE 1. aQd
"ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
V O Lender.No PLUMBING FEE t 00'
LL I-- Larder'.Address QTY. , MECHANICAL PERMIT . . .,FEE MECHANICAL FEE
OW I cedilythatl have read this applkatlonand stalelhatthe above lnfarmait
6 lecorrect.lagreetocomplywlth aH city and county ordinancesand slate laws PERMIT ISSUANCE �4CO FEES PAID:
>_ relating to building construction,and hereby authorize representatives of this
F Z c
ity toPontW abovcmentioned property for Inspection purposes. r ALTER OR ADD TO MECH. S0
Z a to cove,Ind an d keep harmless the City of Cupertino Date Receipt#
tlee,pdgme and expenses wFich may In anyway accrue AIR HANDLING UNIT(To 10,000 CFM).. SUBTOTAL'
ity In con an fthe anting ofthisperedt.
AIR HANDLING UNIT(OVER III,=CFM). CONSTRUCTION TAX
Signa of Appontrctar Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
CMDOUS MATERIALS DISCLOSURE
Will theappllant or future building omupantstore or handle hazardous TING UNIT(TQ)00,000 BTU) a Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 91$and the
Health and Safety Cade Section 15531(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: I
F1 Y" ix]No ,
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REMD) s QO 1$SUAi
which emit hamrdous air contaminants as defined by the Bay Area Air --
Quality Management District? BOILER-COMP OIIPOR 100,000 BTU) ,
> Yee No
I have read the haze ous materials requlremxnts underChapter&95 of BOILER-COMP(OVER 100,(100 BTU)
the California Health&Safety Code,Sections 75505,75533 and 15536.1 tai
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. ry.�
r"ponsibllity to notify the occupant of the requlmmenls which most be met WN/ '
prior to issuance of a Certificate of Occupancy. \/••+a,��`_ITLjw1G[� �,�..,a,
Owner or authorized agent Dale ry - ISSUED 30 V 1✓Usf'l1s•iNt/w�_s
TOTAL:
OFFICE COPY