22149 J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ext Identification I PERM ITNO.
Building Address: 6o L SKfrmtk 22149
TTW.=. am
A
50uTt G?k44 CITY OF CUPERTINO-BUILDING DIVISION _t 0, ct
Contractor's Name: Llc. e: APPLICATION I'PERMIT J L I
Aty C BUfLDINGLLECTR[CA4PLUMBING-MECHAMCAL CATEGORY CONTR g-0
Archite�c/ ,glneee a No:y IO SCJ
Cry ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address: 5 Lt_ LA PERMITISSUANCE (ti �EC7-I 1�/A ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that(am Ecnsed under provisions of Chapter 9(commenc APPLIANCESREEDEMIAL JOB DESCRIPTION
Ingwlth Se on7000)ol Di Won3ofthe Busimmand Pmfe msCode,and m
Ilcense is In full force and effect, PANELS
Ltmnse Cbm LIe M__..((��JJ]]..�/��....s.s��ZZ.. t
Date Contncior�nra�n/✓.ST7
ARCHITECTS DEC RA ON 201-1000
,nal I understand my plans shall be used as public records. 9vFR'OFJtmPs CSQ.FT.FLOOR AREA $/SQ.FF.
(/ Licensed Professional FOTO -CA cz
6 OWNER-BUILDER DECLARATION IAL T/MISC
7 �4 hercbyafOmn lhatlam exemp (romtha Contradare Llnnse aW, Rha
❑❑ following reason.(Section 7031.5,Business and Professions Code:An ty or
FH county which requires a permit to construct,alter,Improve,demolbh,ar air TEMP. -OR POLE INST.
q� anystructure prior to lb Issuance,also requlm the applicant for such ps to
PJ file a signed statement that he b limned pursuant to the provisions o t DM
wF� Contractor's License Law(Chapter 9(commencing with Section 7000)of v
f50;} slon3of the Businenend Profembns Code)orthat hob exempttherefro d Sh4NG C _ VALUATION
<•33 the barb(or the alleged exemption. Any violation of Section 7031 �/t�
aPPBa^t lora permit subµats the applicant los dull realty of rat more than OUTLE ES SSs'3O l Vv, �CJ�t
flue hundred dollarhepr. NE .R pL ECTR SQFL STORIES TYPECONSTRUCTION
�n
71,as owner of the property,or my employees with wages a their sole
compevatlon willdothe work and thestructure is not Intended or offered for
sale CSec.7016,Busineu end Profenlmu Code:The Contrado/s Ecerse Law
S� does not apply to an owner of property who Wilds or Improves thermn,and OCC.GROIIP RES.UM'fS
who does suchwork himselforthrough his own employees,provided that such
Improvements are not intended oroffered for ate.If,howoverthebullaingor TOTAL: 7Zj0
Improvement bwld withinomrarofmmpbtlon,theowner-b-RderwRl b.-
OAA urdenofpmving that he did nm buildminaprove for purpoaeofsale.). QTY, PLUMBING PERMIT FEE
U L as owner of the m FLOOD TONE APN
property,am exclusively a n%'rding with.Codd PERMIT ISSUANCE
contractorsct constrod thew doe(Sec.of apply
Business and Professions Code:
The Contractor's esLictee Law don not apply ct an owner of property who ALTER-DRAIN&VENT-WATER CEA)
Wilds or Improves thereory and who contncb !m such pCojecie with a
cgp[fador(U Bceaed pursuant to the Contractor's Llrenx Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
L-,l I am exempt under See. B&P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEI T M
WORKMAN COMPENSATION DECLARATION FICIUR &PER TRAP SCHOOL TAX Y N
01 hereby affirm that I have o Insurance
a c of convent to copy
thereof
or RECEIPT N
3900,1 eolWorkene'Compensetlonlnsurantt orarertifled ropy thereon((Sec. GAS EA SYSI'EMI INCA OUTLETS
Polis Lab C.) PARK FEE Y_ N_
Policy p RECEIPT M
Cam an GAS EA.SYSTEM-OVER ,
Y BUILDING DIVISION FEES
Centfled copy b hereby filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑CcrtNed copy b(Ibd with the tlty Inspection division.
CERTIFICATE OF MPTION FROM WOR KERS' GREASE TRAP PAID Q2
COMPENSATION INSURANCE SEWER-SAMTARY-STORM FA.200Ff. D RCCC [# 1•-7'
(This wdlon need not be completed lithe permit Ls forone hundred dollars
(91 W) WATER HEATER W/VFNT/ELECTR ENER Y�
Icertrtifyily that b
the pedma
ounof the work/orwhich this perosis Issued, ' yy —
VNA
I shall not employ any person In any manner so as,to become subject to the WATER SYSTEM/TREATING t,/V
Workers'Compensation Laws of California,Date PAID
O.Z ApplicantDTNEW RESIDENTIAL PLMBRte R 1 t#
Z 0 NOTICECE TO APPLICAM:II,steer making this Certlflate .of Ezemplion,you ��
should become subjcd to the Workeri Compensation provisions of the Labor TOT L:
W Code,you must forthwith comply with such provisions or this permit shall be BUILDINGq a
y deemed revoked.
CLCONSTRUCTION LENDING AGENCY SEISMIC
Ihcreby.M that there b a corshudlon lending agency for the perform ELECTRIC
7 Z anco of the work(or which this permit blaued(Sec.3097,Civ.C.) TOTAL:
V O
Lender's Name - PLUMBIN
IL — Leaders Add re QTY. MECHANICAL PERMIT FEE. MECHANx
OW Imrtlfythatlhavemadthbappik tlonandetatethattheaboveinlormatim �-t ,s.sasass
a brorred.I agree to comply with all city and county ordinances and state two PERMIT ISSUANCE I +-x(00 FEES PAI
N relating to building construdlogand herebyauthorla,representatives of
thie 1 /�city to enter upon the above-mentioned property for Wpection purposes. ALTER OR ADDTOMECH. 'h,� - Dale
V _ (We)agree to save,Indemnify an d keep harrrJ m the City of Cupertino
agairstliabilities Jud, b,costsandexpen hick maylnanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SURTO AL:
agAnstsai ity In ce ofthispermit. AIR HANDLING UNIT(OVER 10,ODOCFM) CONSTRUCTION TAX
�S
SI re App t/ ort - Data IXHA[15T HOOD(W/DUCT, CONSTRUCTIOqTAX :
HAZARD SMATERIALS DISCLOSURE _Will the appBanl orfuture building occupant store or handle hazardous HEATING UMT CTO 100,000 BTU) Date material as defined by the Cupertino Municipal Code,Chapter 91Z and the.Health and Safety Cade Section 25532(x)? HEATING UMT(OVER 100,000 BTU)
❑Yes M No
Wllltheapplicanl or future building ocmpant use equipment ordevices VENTILATION PAN CSINGLE RESID) ISSt�pTE
which emit hazardous air roots mant
lns as defined by the Bay Area Air
Qua Iity Ma nagernmt District? BOILER-COMP DFB'OR 100,000 BTU)
4rs n No r
haYvereadtheh a�ousmatcrla requIm,mortsunderChapter6.95of BOILER-COMP(OVER100,000 BTU) �I�IY I #J
the California Health&SafetyCode,Sections 25505,75533 and 75530. 1 77
understand that lithe Wilding don nm currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
respotuibllity to notify the occupant of the requirements which moat be reset
prior to Issuance of a Certificate of Occupancy,
Owner or authorized agent Data e� t ISSUED BY:
TOTAL: a?-
OFFICE COPY