21914 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Budding Address: _ nn 21914
Q SGY1T STE /.v6 /COAr� C'uP n/
era am one:
`c 4L �U71ACWW CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: [dc.Nm APPLICATION I PERMIT 3 �--� I
C&V,%ZD OCA)D 69IT0 BUILDINGELECTRICAL-PLUMBINCMECHAMCAL CATEGORY CONTROL Ya
AA�qitcct/Engineer Lb.Na (7
1.19SIV, h�tC/fA K .S 3' % �'F a � n ' �i e a $' �-, ,,,�;+BUILDING PERMIT INFO- R*
R
QTY ._:: ELECI1tICPERMITy.! . . ,_I$EE'.1, - - --.. .._._ �,,u�?"
Address PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
2,P J
I MhSyi. 70thatDims.in3oftheusinmadPmfessionssed under intwisloAs 9de,and e- APPLIANCESRESIDF.MUL ]OBDESCRIPTION
Incense is Mlon force of d efeion3oflhe Bustnesand['roleslonsCade,and my
license I,In fol force and let PANESLiccP TO 200AMPS T
Date Chs Lice S I
Date _Contractor IIWO /
ARCHITE a used.rS DECLARATION OVERIOOOAMPS SQ Fr.FLOOR AREA f/SQ FI,
p�u m0 Z ]understand my plata shall be asci s public records
Licensed Pro(eabnal SIGNS ELECTRICAL
�<lg OWNER-BUILDER DECLARATION SPECIAL CIRCIRT/MLC
Ihereby.M.tlmt lam exempt front the Contractor's License Law forthe
Q following reason.(Section 70315fesslo
,Business and Pms Code.Any city or TEMP MEITROR POLE INST.
cmntywhichnquimaper mmrmtruct,alter,Lnpmve,de=lWh,ortepair
anystructure prbrrolts hanase,oleo requlmtheapp0cant(oranch permit to POWER DEVICES
¢
Q file a signed staternt that he In B¢nsed pursuant to the pronas loof the
S a Contractor'.Lcese law(Chapter9(mmme.cng with Section 7000)d DIN- SWIMMING IDOL ELECTRIC
30 Yon 3 ofthe Business And Profesbna Code)crthat he Is exempt therefrom and VALUATI
• y.' the bash for the alleged exemption. Any Violation of Section 70115 by any OUTLETSSTNTCFISFDCTURFS y+-
5 <3i app0¢nl fora perMleubjecb the appllrant too tlVilpemlty o(nrt trortthan '�I 7
fHc
five hundred dollars(SM. NEW RESIDENTIAL ELELTR
�n ❑I,as owner of the property,or rey employees with wages u their win �'�' STORIES TYPECONSIRIX:TION
compensation,willdo the work and the structure h rotWended or offered for
C O sale CSo.70K Business and Piefeslom Gude:Th.CoMactore License Law
$ donor apply to an owner of property who builds or tmprwn Hereon,And
�^ whodanmchmrkhimxV¢throu hbowneml OCC.GROUP R6 UNTIE
Improver ntsa¢notintenow orrofc pldio the14ha ver,lhebulldingorhave TOTAL -juju
bnprovementbmldwilhlnoveyearolcompldlon,theownervbullderwOlhave �,
tl�urdenofproNngthathedldrobufldorlmprove!¢purposeofsale.). Q'j'y, .a„ "PI.Uli1B['IVG,PERMIT FEE''A -
Lj L ss owner of the property,am exclusively contracting with horsed FLOOD ZONE .APN -
conmctontomstructtiuprojed(See70K Bushes and Profesbrs Cade: PERMIT
the Contea¢ota Lkxaue law does not apply to an owner of property who �.�_
builds or improves thereon,and who contrasts for such PVojects with a
ryBjTactarW Bomsed purauantto the C011baROra License Law. BACKFLOWFEESUMM(IRY;'
LJ I am exempt under SmB k P C for this rcannI UT
.,..ri Owner Date DRAWS - Y RECEBT0_::t k:` �+"' r`•,'r)'
WORKMAN COMPENSATION DECLARATION pEg SCF] TAX::Y_ N_al: ,
QI hereby affirm Wt 1 have a¢rdfl¢te of const ro ssV-Inane,¢a +:$.,. RECEIPT I•rC_•Y t;'a;
.rt".teofWorkes'Compesati%In mm¢aoeYilled copythereofiSec,
AEA 1ctioumE3800,fabCd PARK+F�E-• � REEIN
-A
policy tl TI Wira
Cam any GAS EA.SYSITM-OVER 4(EA) BUILDING DIVISION FEES :..z-tk?ifY
Lj Certified .
z
copy is hereby furnished. GREASE/1NDUSRtL WASTE INTERCEPTOR PLANCHECK FEE '•`'c+v:%'•i't'L
F Certified copy is filed with the city inspection dlvWn.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SETVER•SANITARY-STORM FA 20017 _ Date !�'-e".slReeei (# i7a?'bf".-.�"
(Thio action need not be completed if the pends bforos hundred doom ENERGY FEE - ,!4Ra
(O�¢rHlytiut tsthe pedoman¢o(thework(orwMch llW pemdtbimed, WATER BEATER W/VENT/aMGM . _.'_ -P _.•1r,:
1.h U n¢employ any pereon in any manner w s W become abjeet to the WATER SYSTFCH/TItEAIlNC •• �`.....
Worken'Compewtbn law.of Callfomb.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. PUFL Date Rete t#
Z O NOTICE TO APPLICANT.If,
,after making this Cremate of Faemptlaa,you
PN should become subject to the Warks¢'Camperuatlan prewbbts of the Labor TOTAL
a. ; Code,you mut forthwith complywlth such pWs
nweorthb pernW shalibe
1V G deened remked. BUILDING FEE
cONSTRUCTION.LENDIIG AGENCY SEISMIC FE
CL Z ¢therebyaLmthat than bamruttucHonlending agency forth.perfrm ELECTRIC FEE .. p
anof the work for which thla permit h loved(Svc.3097,CW.CJ '
f, O Lander.Name - - -. a PLUMBING FEE ,. •',� .�. 5,.::'^;t,:
I- Lender.Addrn. QT7 E'� ME_ CAL EEE. - I;-,�..a,s -.
O w 1¢YVythat l have read thhapplhatbnand smathatov
the abe Wonim on - MECHANICAL FEE ^c'r
„. - � 1. 'rl_
bcorrect.I agmto comply with act etyand minty ordinances and Mate laws PERMIT ISSUANCE FEES PAID: ^.•I"^ il:,.^�, ,
} N relating to building mstroctfon,and hereby authorl repreaentathen of this p -y.
F
city roeNer upon the above•mentlosd property fa Wpectle.purposes. ALTER OR ADDID MECFi. rr .141ss 100
? (We)agate to save,indemNly an d keep hamdes the City of Cupertino Date :.ReceI t#.2, v•..' :-
V agaEut 1011es,judgments,coasand,expenses which my In anywayaosue AfRHANDlUNGUNR(TOl0,g00FMSUBTOTAL
ityin n. geC
'aga d cm � p .r¢ AIR HANDLING UNIT(OVER laaBCFM) CONSTRUCTION TAX ,:>I•.. .;f��
sig reofAppVant/Contrmor to EXFIA1.51HCOD(W/D13CD CONSTRUCTION TAX PAID: -, ;•u���R_
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDate - ReCel t# ! y�
material as delved by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532WT HEATING UNIT(OVER 100,000 BT(B ' TOTAL: t)
n❑Yn No
Wllltheippllcentar No VENTILATION pment¢d
equlevlm VFMTIATION FAN(SINGLE REBID) ISSUANCE DATE
which codt hanrdoua air mntamW neve as deftned by the Bay Arta Ab
�uality Management District? BOILER-COMP OHPOR 100,000811)) P!L✓rM1y
I I Yn n No ?..
thavereadth.havwsnutcHabrequbemenbunde,Chapter59Sof BOILER-OOMP(OVER 100,000 BTU) Rf R r•�QQt
tk Callfomh HealthkSafety Code,SMlos25505,25S33and2S531.1 rt J �h�/✓V _
understand that If the building don its,mrrently lave a tenant that it is my NEW RESIDENTIAL MECH. SQFr. '
responsibility to notify the oc upare of the requirements which cost be met e,tl
prior to issuance,d a Cerllllon of Occupancy. NOW" '
t Owner or authorised agent Data
TOTAL, ISSUED BY:
OFFICE COPY