21815 APPLICANT TO FILL IN INFORMAT10N WITHIN REDLINES — USE BALL POINT PEN ONLY
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Building Prelect Identification �r PERMITNO.
s a�I tl_/Dp-`L�021815
ane:
CITY OF CUPERTINO-BUILDING DIVISION �• _
cona1ayeotaN.ame: I• c.No: APPLICATION / PERMIT
V`,v P-1D U_ �" 476 I ' O BUILDING-ELECTRICAL PLUMBING MECHANICAL CATWORY CONTROL N
ArehltNsl/neer. LIc.No:
- Qra 'S t ` ,",t`�i BUILDINGIPERMIT INFO
"i'.y; 'i S I?GHCTR[C PERINIT'1-. (ay( �It4FEB, )
Address: tig_truyCONTRA `/1 ow •x-3 ' ` PQ2MIT ISSUANCE
LICENSED R'S DECLARATION - , 0
7herebyafflrcelhat l amlicensed under provislonsof Chapter9(mmmo-
mAPPLIANCESRFS[DENTTAL JOB DESCRIPTION
IngwlthScctom7000)of Dlvlslon3 ofthellusloessand ProfesslonsCods,and my S aN'••^••�s �-j
license Is In full and died. O PANELS Yv Y
OR _Canhacmr1 `d�•'(���-D — UPIQ200AMPS
ARCHITECT'SDECLARATION 201-10D]AMPS - - koj r
p�pa�++0 CpC l understand my pkw shall be used as pub4c records. OVER IDIO AMTS SQ.F r.FLUOR AREA - S/SQ.FT.
k I�U Licensed Professional - SIGNS ELECTRICAL - -
<< m a
�j OWNER-BUILDER DECLARATION
t`n a Fii '' SPECIAL CIRCUIT/MISC
t..,Yrs Thereby affirm tlutlam exemplfmmlhe Cnmraaorb License Law(or the `
following reason.(Section 7031.5,Business and Prefeselons Code:Any city or ! TEMP.METER OR POLE INST.
county which requires a permit to mrutruct,alter,improve,demolish,or repair
q1 any stru .prior to its issuance,a qui res the app least for such permit to POWER DEVICES
E5 C file a signed statement that he is licensed pursuant to the provisions of the
O Conuactore 1Licenselaw(Chapter9(mnurcndngwlth Section 7000)of VIA-n SWIMMING IDOL ELECTRIC
30 tion3 ofthe Bagressand
alleged exemption.
Any)virthatheis exempt therefrom and VALUATION
G
the basis for a Nrrleged exemption. Myt tola civil p Section n cobyany 'O OUTLETSSWITCHESFT%TURES 11 `
Q fleeapplicantdred deemdtsubjectsthe applicant los dull penalty o(nd more than
flue 1,as
owner
of the., NEW RESIDENTIAL ELECTR SQPT, _v
❑1,as owner of the property,or he employees with wages r thele sok STORIES TYPE CONSTRUCTION
compensation,(Sec.7K wiltBothe work and ions Code: h not Intended orofferedfor
❑ doe nota apply
to anownerof propc oro Code:TheorimpContractors themoLicense Law
r'$ whodotapplytoan owner ofpropertywhom employees,
provided
tatand
�3^ whodoeesuchworkhimeeRmthroughhisownemployes,provided thateuch OCC.GROUP RES.[MRS
Improvements am not Intended oroffered for sale.If,however,the bulldingor TOTAL: 7,Cp -
Improvement lssoldwithin one yearofcompletion,the owner-bu0deiwill have
th kordeno(pmvmgthat hedid nabuild orlmprove for purpoico(sale.). Q't`y. I „ ALIMBING PERMIT . 'I' t,FEEFLOOD ZONE APN
u 1,as owner of the property,am exclusively contracting with licensed
contradoralo construct the project(Ser.70K BualneesaM Pro(esirma Code: PERMIT ISSUANCE 1•��
The Contractor's License Law does not apply to an or M property who •ALTER-DRAIN k VENT-WATER(EA)
builds or,Improves thereon,and who contract for such p(npcts with a
ro,lpBI7fador(s)licensed pursuant to the Contractor's License Law. „ r i .',FEE SUMMARY
u I-are exempt under'Sec. B k P C for thin reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
DRAINS F7.DDR ROO$ARG,COND. SANITARY Y N
Owner Date RFCI7PT R
46WORKMAN COMPENSATION DECLARATION �L FLY.IVRF_S PER 7RAI' !` 5CI100L TA% Y N
❑I hereby affirm that I have a mrliBcate of consent to self-Insure,or J 1Dx� RECER NN
certlflcata of Workers Comperwtlon lrrsurance ore artl(kd ropy thereo((Sec. GAS EA.SYSrEM1 INC60ITILETS. PARK PFR 'Y N
3500,lati C.) -
-Tory GAS EA.SYSTCM-OVER 4 G)
' RECEIPT#
Corm BUILDING DIV
ISION PIi ESMertlfed
copy is hereby filedwfume city GREASE/INDUSTRL WASTE INTERCEPTOR PLA NCHECKFEE
�Certlfied copy is filed with the city inspection division. ,
REARAP
CERTIFICATE OF EXEMPT ION FROM WORKERS' GSET PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIl7RM EA.XIOFT. Date Retel t#
(Thlssection need net be completed if the permit is f irons hundred dollars
(910o)orlcss.) WATER HEATER W/VFN'I'/ELFLTR ENERGYFEE Y N
Icertifytha[In the performance of the work(orwhkh this permit la issued,
I shall not employ any person In any manner so b to the WATCR SYSTEM/TREATING. PAID
Workcra'Cor�pepf C�If TnyyD3to;� "
O Z Applicant }!'IQ �1 F-�1 V� �` NEW RESIDENTIAL PCMB.. T. Date RCC21 [#
Z O NOTICE TO APPLICANT-.It,after making this Certlflete of Esemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N
Code,you=at forthwith comply with such pruvisioru or this permit shall be 13UIL I FEE
-�
W > deemed revoked. 1
C CONSTRUCTIONLENDINCACENCY • SEISMIC-FEE Lal,
Il Z I hereby affirm that there is a construction lending agency for the perform - TOTAL: 1 ELECTRIC FEE
O sono(the work which this permit is Issued(Sm.30W,Civ.C.)
Lender's Name PLUMBING FEE
OH Lender's QTY. MECHANICALPERMIT IFEE LL - - MECHANICAL FEE '
O W comd.I agree
toeave madtcomply
with allatyand c statethaitheaunyonflear us andformation '
a isroingtobgreelocomplywlth alndtyandrountyixerepncesand gate laws PERMRISSUANCE FEES PAID:
W rektlng to hullding conewdlon,end hereby property
orize pecu..purposes.
F iit Menteree to the indemnify an
property Wpe Cit purposes. ALTQtORADD TOMECH.
Z Date Recei t#
(We)agree to save,indemnify and keep eharmless which the City of yway Cupertino P
O ago t7labiiltks,Judgments,met and expense which may In any wayattroa AIA IiANDLINC[1MT(TO 10,000 CPM) '. SUBTOTAL:
Zai aid City In cimssiour glRnting ofthlspermitz/b/9
aklv.NouNcUNIT(OVER 1R,rooclr) CONSTRUCTION TAX '
Signature of Applimet/Contractor Date E%HAisrHOOD(w/DUCT) CONSTRUCTION TAX PAID:
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0006111) ' Date - ReCel t#
material as deflond by the Cupertino Murddpai Code,Chapter 9,12,and the -
1 lealth and Safety Cale Section 25532(a)7 HEATING UNIT(OVER 100,000 BTI)) TOTAL:
Yes r!No -
Willtheappllcanlorfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whip emit hazardous xir centareleants as defined by the Bay Area Air
Quality Management DutnC7 BOILER-COMP OM'OR 100,DM BTU)
-•eghy"' gNo
` havcread Inaltha mmatde,Section 2m05,2553and55M. 95 of BOILER-COMP(OVIRIW,BOO BTU) 'La1
the Califodt at Ifthe building
Code,not carr ntlyh have
atennd,that 1 FP
understand that lithe building doe not currently have atenanL that itismy NEW RESIDENTIAL MECH. SQ.FT. - a
responsibility to notify the occupant of the requirements which must be met -
prior tolssuanreofa Certiflmteof Occupancy. ., Gk Of.rmswil' Iy 11
Owner or authorized agent - Date ISSUED BY: �a s_�•w �l YaaLaR4V"�a rJ•
TOTAL: '
OFFICE COPY,