21673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification 7 PERMIT NO.
Building Address: 21673
1"7 scot V er6(a s iJr•
NIr, �7 A A
FF,4Dz)W_5 Zs7'— "3 CITY OF CUPERTINO-BUILDING DIVISION
C
ps/ d,rtName: APPLICATION if PERMIT ^
1 A✓AN'W T ` one,' APPLICATION
CATEGORY CONTROL#
Archited/Engineer. k.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOC ELELI PLUMB MLCH
Address: PERM1BTISSUANCE
LICENSEDthat ICONTR under provisions
RATION
I herebyaBkm dullamlkensedhe Buidessand Proemionsr9adeand c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith SI f III 00)0(deff et 3ofthe Budnessand Pro(esslonaCade,and my
license is in full force net dfect. PANEIS y
Llcensq Class V— Lk.N J� 39� V 6 fl RP+
Date / N Cmdrad.r 0.I h COAC, UP TO 2DO AMM
ARCHITECPS DECLARATION 201-10DOAMPS
02 (understand neyplaosh
aallbeused aspublcrecords. OVERI000AMPS SQ.FT.FLOOR AREA
�y O
ll�j Licensed Professional SIGNSELECTRICAL
Q OWNER-BUILDER DECLARATION
Nn}Fn tNRV
L CIRCUIT/MLSC
Ilideto 7y owing rason.(hction7 IS,Buampt roessa Contractor's License Law fort he
OOZF following reason.(Section 7mtS,Business and Professions Code:Mycity orMETER OR POLE 1W.
countywhlch requbna permit tocosntruct,alter,Improve,demollsh,or repair
F � anystructum pdorto its lsdance,alao requlresthe applicant for such permit toR DEVICES
C c. file a signed statement that he is licensed pursuant to the provislOru of the
Contractor's License Law(Chapter9(commendng with Section 70W)of Dlvf- dRNG POOL ELE RI VALUATION
O sion3oflhe Budnosand Profmn mCode)orthathebewmptthercfromand
<, the basis for the alleged exemption. Any violation of Section 7031.5 by any TCHESE �Q�D s L/ei
applicant for a perMl subjects the applicant m a civil penalty of not more than J
n, R five hundred dollars(55 L ESIU AL ELEG SQ.FT. STORIES IYPECONSIRUCTION
❑1,as owner of the property,or my employees with wages as that sole
mmpansation,willdo the work andthe structure b not Intended or offend for
Osale(Sec.7004,Business and Professions Code:The Contractots License Law
does not apply to an owner of propertywho builds orimpreves thereon,an• OCC.GROUP RES.UNITS
EE who doessuch work Mmselforthmugh Wsoweemployers,provided that we
Impmverrcnbarenot intended oroffered for sale.IL howevegthebulldingor T TAL:
improvement bsold within one yearofcompldion,the owner-builder will have
t burden of proving that he did not build or Improve for purpose of sale.). N. PL ING PER FEE FLOODZANE APN
L as owner of the property,am exclusively contracting with licensed IT ISSUANCE
contractors to construct the project(See 7004,Business and Professions Code:
TheContractors License law does not apply to an owner of property who ALTER-DRAINk VFM- )
bullets or Improves thereon, and who contracts for such p(ojeda with a FEE SUMMARY
on doRa)licensed pursuant to the Contractor's License Law. BAIX FLOW PR EC D E
LJI am exempt under Sec. B 4 P C far this read, SANITARY Y N_
DRAINS FLOG R roND.
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES-PER SC1iOOL TAX Y_ N_
f hereby affirm that I have a cerdfiate of consent to self-#core,or a RFGEIPT N
mrti late O(Worker4 Compensation Insurance or a certified ropy themsfthee. GAS.EA.SY -t NCAOUTLETS PARK FEE Y N
3800,Lab C.)
RECEIPT N
I'ollry N
CGAS EA.SYSTEM-0VRR 4(EA) BUILDING DIVISION FEES
Eom any
Certified copy b hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Sit Certified copy b filed with the city Inspection division.
IW CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MET. Date Remi t#
(Halt section need not be completed lithe permit Is for one hundred dollars
($10D)or In..) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
I oertlfythat N the performance of thework forwhuch thus permit Is Issued,
1 shall not employ any person In any manner m a to become Whiled to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Data
PAID
O 2 Applicant NEW RESIDENTIAL PLMB. SQF. Date Rami t#
Z O NOTICE TO APPLICANT:If,after making tads Certificate of Exemption,you
should become subject to the W,rkers'Comperwt ion provisions of the Labor TOTAL: '.�•a
N Code,you must forthwith comply with such provisions or this permit Asti be ILDING FEE
deemed revoked.
W , CONSTRUCTION LENDING AGENCY SEISMIC FEE t
CL I herebyaffirenthat there Is a mmtructlon lendingagency forth perform TOTAL ELECTRIC FEE
7 2 anceofthework forwhichthIs permit Is tsaed(Sec.3097,Civ.C.)
Q O 1< PLUMBING FEE
nders Name
LL I— I.endce.Addreat QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
i¢dlfy that l have reacithbapplimtionand state thatthe above Information
O W
G bcorrect.l agreeto comply with all cilyand county Ordinances and state laws PERMIT ISSUANCE FEES PAID:
T relating to building construction,a od hereby authorize representatives of this
V) city to enter upon the above�mentloned pro rtino
rty(or'inspection purposed. ALTERORADDTOMECH. Date Recei t#
V a aWt liab�es yN.vc,�td,cortsande as 4hich ma Cityit fCupe�e AR HA NDLING UNIT(TO 10,"CFM)
g y you yes SUBTOTAL:
agal 1 ance rthe ofthi.p t CONSTRUCTION TAX
con AR HANDBAG I1NR(OVER 10,000 CFM(
av'
nature,(Applicant/Contralitur R e — EXHA115'H HOOD(WI DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCIASU RE
Willtheappllcant or future building occupant store or handle hazardous HFATING UNIT(TO 100,000 BM Date Ret:6 t#
material as definM by the Cupertino Municipal Code,Chapter 9.12,and the
I Icahh and Safety Coded-aStection 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Ycs or No
Wllltheedt apphcantorfu onto minding occupantusethe BayequiperentArea devices VENTILATION FAN(SINGLE RESIU) IS6U DATE
which eMa hazardous air mnta Mnants as defined by the Bay Arca At,
rr
Quality Management DisWNo BOILER-COM('OHP OR i 00,0M BTU)
Ycs
4have read the haaaRoat us rvteriald requirements Chapter 6.95 of BOILER-COMP 100,000BN) Jr1a
N 14 1951
the California Health A Salary Code,Sections 25505,25533 and 25530.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH.
responsibility to notify the occupant of the requirements which must be met, �taa/sS�0.as.t�-�tl
prior to issuanceda Certificateof Ompanry. R�!�(31 DY.o'pt�L,lJ'n'(t7�� yt��
Owner or authorized agent Data ISSUED BY:
TOTAL:
OFFICE COPY