21580 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
building Project Identification - PERM NO.
Wild lag Address: - - f�a�
O 9D TT< . G I •Vl}VS
w ante e. ,
!�Q/1 CITY OF CUPERTINOBUILDING DIVISION c' �_
ca sera tie: Li=.Na APPLICATION / PERMIT .7: 7 ' /
_ - BUILDING-aWTM(A1,PLUMBING-MECFIAMCAI.' CATEGORY CONTROL p
Architect/Enginrer.- • Lle Na:
'��ti BUILDING PER
INFO
.Q'LY+i r r ELECTRIC PERMIT t.{n, i.'dITEI'. i.. ..
Address: PERMITISSUANCE El ❑ ❑.
LICENSEDCONTRACTOR'SDECLARATION -
Ihercbyaffirm that l am licensed under provisions of Chapter9(comment, APPLIANCES-RESIDENTIAL - LOB DESCHH'TION
Ingwilh Saction 9000)of Division3ofthe Businemand Pmfessiom Code,and my
Lienee Is In tui d fret ;. _ PANELS
Ucen Contractor
onti' JVai /
Date - GHAT r ARAT11 it Zp11000AMPS 5�@'rsYs l'
LM IQ 2DQ AM5
ARCHITE D:CLARATIO - L lir � I� ,
a7 I understand my plana shall ba used as public records. OVFR1000AMM R $/9Q.Ft.
OO
Licensed Profoolonal SIGNS ELRCTRICAI.
6 OWNER-BUILDER DECLARATION -
C, SPECIALCIItCMT/MISC pp.�� R
Dowfinbyason.(hatlam31.5,Bexempt frmrithe Contractor'sL Ocala:icause nychym-for the 1 • •
'Z "'o foOowing mason.(Section 76715,Bueinesa and Profeaelons Code:Any d1y or /T5/�
Fauntywhlch requlresa permit torontmct,alter,impiove,demolishorrepalr TEMP.METER OR POLE INST. T r -
g� anyatrudure prior to its barance,also requ bas the applicant for such permit to
f5 yi file a signed statement that he as licensed pursuant to the provisions of the LOWER DEVICE . - y'
3� Contractor.License Law(Chapter 9(commrnwithS
cingecti7000fD
Section I'nSWIMMING POOL ELECTRIC
thebasftheBuslneaeandexemptlonC Any
of
therefrom ane - VALUATION
< the basic for the alleged exemption. Any t tola civ:of nSection 7 ea room
by any OUTLETS.SWITrHE&FIX URES
applicant fora peri.(subjects the applicant to a dull penalty of net more than ./.
ofoo hundred
ner of the property,
NEW RESIDENTIAL.ELECTR -
tGG511 ❑I,asownerll theproperty,or my employerswith waters as their sole �'�' SIORl Tl'rE CONSTRUCTION
1.
compensation,04C Bustrotheworr endthe ions Code:ure
ot Contracded orofferedLfor
s p 'sale(Sec.apply
to as owaoss ner
df property who
The Contractor's License Law
( $$ don not apply roan owner orthrou h who nporlmproovided that and OCC.GROUP RIS.UNITS
c.
who does such am nothimself ndedoroughed own .If,hoemployees, er,thedlhatauch
improvement are not Intended orolfered for cele.If,however,thebuilding or ,TOTAL: -
+ Improvement isseld withinoneyearofcompldiogtbeowner-budderwUI have -
thet;urdenofprovingthathedidnetbuildorImprove for purpose of sale.). QTY, 1•PI:UM6INd ERMIT� I' FEE" FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
coR
ntraorsto mnatrut the project(Sec.7044,Buslnen and Profession Code: -
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improvn s
thereon,and who contracts for so& ptojes with a .t)1PEE.$UMMARY ''�t: ,
c,Rt{actor(s)licensed pursuant to the Contractor's License Law. .�), 1.1 ;
L.t I am exempt under See.' B k P C for this rcnon HACK FLOW PROTECT. - -
DRAINSFLOORROOF,AREA,GOND.' SANITARY Y N
Owner - Date RECElpr N
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y_ N_
hereby affirm that I have a certificate of consent to self-Insure,w a _ _ RECEIPT M
\ :Rate o(Workea'Comperuatlonlnurance araartl(Ied copy thereof(Sec.
3500,Isis C.) S�� ys/F a GAEA.SYSTEM-1 INCA OUTLETS PARK FIT. Y_ N_
Policy �O•�a�3• GAS EA.SYSTEM-OOVER RC=F#
Com anv��QQ - HUI LDING DI VI SION FEES
(�ceninea copy V hereby(umbhed. CREASE/INDUSTRL WASTE INTERCEPTOR ' - PLANCHECK FEE
Certified copy B,filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2006T. Date Recei t#
(Thlssection need me be completed if the permit b for one hundred dollars P
($]00)ntifytJ WATER HEATER W/VENT/RLRCTR ENERGY FEE Y N-
Icertifythat in othe person in sof thework so as to b co eermitsubj c Loured,
I shall not employ any person in any manner n an to become subject to the WATER SYSTEM/TREATING >
Workers Compensation Laws of California.Date LAID .
Z plicant
0 NOTICE TO APPLICANT:I,after making this Certificate of Exemption,you NEW RESIDENTIAL PLM S. SQ.FI'. - Dale Recei t#
H
should become subject to the Workers'Compensation provisions of the Labor - TOTAL:N Code, swat forthwith comply with such provisions or this rrrddshall be
K j deemed revoked. Py F BUILDING FEE -
W — corvsrgucrloN LENDING AcrxcY SEISMIC FEE f
a.G I herebyaffirmthat there le a roravuction lendingagency forthe perform ELECTRICFEE'-
7 Z anceufthework forwhichthis permit ex issued(See.W97,Clv.C.) TOTAL:'
(1 O Lender'sName - PLUMBING FEE
f Lender's Addmea QTY.
MECHANICAL " FEES:
W lootlfythatl havereedthisappliculonand statethottheabovel.imenallon - MECHANICAL FEE
CL cormt.I greetocomplywithall cityand county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
W mlatingtobullding construction,and hereby authorize mpmsentativn ofthb
F '
Z - city to enter upon the above,mrntioned property petion purposes. ALTFRORADDTOMECH.
agree to rave,coda I1y an a keep har the Cay of Cupertino Date' Receipt#
U
as labllltin jvdgmenb costaand glpeners Ich may lnanywayaccrue AIR HANDLING I NIT fro 10,000CFM) 'SUBTOTAL:
a Wt old Cit icons are Fanm this emelt.
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig tumo(Appllant/Contras r can, EXHAUST HOOD(W/DUCD. CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Wllltheappllaratorfuture building occupant store or handle hazardous', HEATING UMT(TO 100,000 BTU) _ Date RCCEI t#
material as defined by the Cupertino Municipal Code,Chapter 9a 2 and the -
Health and Safety Coad Moon 75532(a)1 HEATING UNIT(OVER 100,000 BTM TOTAL:
Wllltheippllcan4.m building occupant use equipment or devices VENT:LATION FAN(SINGLE RESID) [�f�I�E DA'Z'E ,
hichemlthammlontamlwntaasdeMedbythe Bay Arca Air
QualBy Management Di t7 - - BOILER-COMP DHPOR 100,IXD BTM Q.�ya
4 Yrs o ' 1�aG
have mad thch r ous materials requirements under Chapter 6.95 of - BOILER-COMP(OVER 1fA,000 BTU) t
the California liealt Ac far Code,Sections 25505,25533 and 25534, I 1+1$T F
unciers that if Cbuildingdoes not comently Its ant,that It b my NEW RESIDENTIAL MECH..' SQ.F.T. ,
raps slblltytonol then ant oft Aire which must be met
pto
City
t once Certlfi Y �t RR
OlEfrmarthodaed agent _ Date
TOTAL: ISSUE O V CL
OFFICE COPY