21023 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
I
building Project identification PERMIT NO.
BuildingAddress: e LvSSO� I),-k . 21023
N�j eD T2 S Cg+
acre ante: one: - p A
Zk64 me— Ca Tree -12ag-13'ZbC CITY OF CUPERTINO-BUILDING DIVISION n
wi rontradora Name: APPLICATION / PERMIT V
6
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N/
rehired/Engineer. $Sy��}�
ELECTRIC PERMIT
• {i PEE BUILDING PERMIT INFO
Address: 9 ML
4Z �,kTsy+.L ''QTY• ' ,; -
PERMTISSUANCE <a W
LICENSED CONTRACTOR'S DECLARATION ysN
Ihereby affirmthat l am Rcrosed under provbionso(Chapter9(comment APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth in
7000)Oforces and
Bucndssand Pro(evlonsCode,and my ��� ^��`o- '
license b In fuB toren and d(ect. PANELS K
License Class Lle.p
DateContndor -
ARCHITECI'SDECLARATION 271-1000 AMPS
q�q�uu9XIunderstand my plarushall be used as publicrecords. OVER IOW AMPS SQ.Fr.FLOOR A.�r/f'rE/SQ.Fr.
F1
50 Licensed Professional SIGNS ELECTRICAL
<«<�<Lq OWNER-BUILDER DECLARATION + SPFLIALCIRCUIT/MLSC JC7x OO
tflrmtiJ l L1 C
71.., Ihembyathat lamexempt fromthe Comoseor's Licenv law forthe
following reason.(Section 7WIS,Business and Professions Code:An d r
Fl, county which requires a permit to com uct,ager,Improve,demolbh,or repair TEMP.METGR OR POLE[NST.
< a nystmmmpeortoit ismance,alsomquimatheappliantforsuchNrmltto POWER DEVICES
U Ile a signed statement that be is licensed pursuant to the provisions of the
3 u,� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
F,�OS don3ofthe Buenevand Pmfenloru Code)orthathebemmpttherefromand I VALOATIO O
6 the bash for the alleged exemption. Any violation of Sedion 7031.5 by anymd OUTLETS-SWITCHRSFIXCURFS. I
�j applicantfora pedt subjectstheapplicamtoa civil penalty ofnmarathonrk— t
6 Off] five hundred dollars($500).
of
❑I,as owner of the property,or my employees with wages as lhelisole NEW RESIDENTIAL ELECIR SQ.Fr, ]FLOOD
7APN ECONSIRUC'IION
7Q compenaatlon,wllldothework andthestructure enot Intended or offered for
O vie(Sec. pply loalnowner and Professions Code:TheCImproves License Law
$$ does out apply torn imscIfor ofprough hisonempWilds oyees provided
that such
GROUP [WITS
whodoesents each amrktintenedoroffe downs.If,ho ea,providedthatsuch s�
improvementsarenotintended earofc pleioe.If,however, rider illn ve TOTAL:
Improvement bsold wlthinoneyearofcomple0on,theownerbu0derw111l�ve
t nufprovingthathedld not build or improve for purpose ofsale.). QTY, PLUMBINGPERMIT FEE7ANE
owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE .N1
nlractas to mnslru,t the pm)ed(Sec.70W,Business and Professloru Code: W
C.Moines License law does not apply to an owner d property who
FALTER-DRAIN& -WATER(EA)
Bds or Ime provthereon, and who contracts for such pwieds with a
copjrador(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
LI 1 am exempt under See. B k P C for this reason BACJVLOW F301UCT.DEVICE
Q11TS1nF F1 17R
Owner Date DRAIN F,ARESANITARY Y NA,GOND. RE-CEIPr#
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sel6lnsum,or S (`� SC{OOL TA% RLCEIRNp
canl(IrnedWorkera Comprosationiruumaca,.amrularecopythardu(See. GAS. 1 PARK FEE Y N
Policy N GAS EA.SYSTEM-0V- 6 RP.CFIPC p
Com any RUILDINC DI VISION FEES
en s,
copy is hereby furnished. GR TER—CrMCR PLANCHECKFCE
C]CertRied copy Is filed with the city Inspection division.
Ila vo
CERTIFICATECOMPENSATION
TION I N FROM WORKERS' PAID
COMPENSATIONINSURANCE SEWER- RM EA 201' Date RCIX`I IN
Qhlasedion need rad be complded[(the permit E forams hundred dollars
(St I o mIsm.)
WATER IiFA EGTR ENERGY PEE Y N—
I
V
]certify cop in the Performance personinany manneworkr
so as to b. p reeltsubject
c loved, -�
I shall not employ any person In any manner m u to become subject m the WATER SYSTEM/TRFA77
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENDALPLMB. Date Recel tit
2 O NODCETOAPubject APPLICANT: fter orkerakirg s'Com ar ation catepro of Exemption,you
Hshauldbecomeftailoto the Workers'Comperuelon provisions permit s Laborbe TOTAL: �a
�) Code,you must forthwith comply with aucM1 provlalov arthis permit shall be
W > deemed revoked. BUl IN �.l• op
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1hembyaffire, hat there is a mmtrunlon lending agency for the pedormr TG.pAL. / ,�aayY-; ELECTRIC FEE s�
ance ofthe work for which this permit is]awed(Sec.3097,Cly.C.) b .W
O O lenders Name PLUMBING FEE19
IL Tenddrapddrerr QTY. MECHANICAL I FEF MECHANICALFEE M3
O W I certilythatl have read thisapplicadmnand statethattheabove information
4 bcorred.I xgreetocomplywitball dlyand cmatymeloancenand care laws PERMIT ISSUANCE �(� FEES PAID:
} U) relatingtobulidlegconewnlon,and hereby authorize representaBvesofthb M
F.Z city to entero above-mentioned Property for W
(Wea pnnion purposes. ALTER ORADD'1C3 METH. x Date Recei lif
— ) to ,Indemnify an d keep harmless the City of Cupertino P
.g. all ills ' dgmenn cocsand ex swhtrhmaylnanywayaceme AIR HANDLING UMC(TO 10,00 CTM) SUBTOTAL:
agal said In consequenceofthe ant go(t a rtnit.
9 AIR HANDLING UNIT(OVER 10,0)0CFM) CONSTRUCTION TAX
i
Sl atvrcof Applicant/Contractor pate IXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATINGUMT(TO1W,000BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reeei tlf
Pkallhand SafetyC7str=�
o 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Y–E.\
❑Yes Will theappllvnbuildingoccvpanture equipment ordevlcea VIiN'RLATION FAN(SINGLE RLSID) ' 1$ NCE DATE
which emit hazardomimntsasde0nedbytheBayAreaAir V
agemenBOILER-COMP OHP OR 100,00)BTU)
dthehazaousmaterialsrequirerrcntsunderChapter6.95of BOILER-COMP(OVER 100,000 BTTqpa Health Idly Code,Sedtom 25505,75533 and 25530. Iahat if building don not cumotly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FToilXy,t eoccupant of lherc ntswhich must be met ��caolaCcrtifica(eo(Occupa S a�( E^�lYy
Ow cr or aulhorlud agent ate ISSIIEU BY:
'IOTA L: TUFF
OFFICE COPY