21410 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Huilding Project Identification - PERMIT NO.
Building Address: - /'�� A r� O
G 4 I
w ere - Ph.e:
�� a ��QdS737KJ9$ Z,s'3'ZZBS �HUN SUHMII-IAL J=
CITY OF CUPERTINO-BUILDING DIVISION ; � l
(� atoraName: No: APPLICATION / PERMIT '
RVIY BUBLDING-MECTRICAI.PLUMBING-MECEIAMCAL CATEGORY CO OL p
Architect/engineer. Llc.No:
BUILDING PERMIT INFO
"') ,ELECTRIC.PERMIT j ) ,t �� FEE
Address 3VNNYA pUWTISSUANCE '. . . El `
LICBNSEDCONTRACTOR'S DECLARATION -
I hereby affirm that l am licensed under provisions o(Chapter9(mmmene. APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Sedion7000)of Dlvlsim3oftheBusinmsand PmfesalonsCode,and my P�,(,pyg/N�r �E''P1PL
license is In full fora and.flet. PANELS
LioD.hn'
Class p_LIc.I, Ale2_13
ARCHITECTS DECLARATION X11-1WOAMPS -
5/SQ-7. 1 understand ney plaru ahal be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA
FT-Licensed I'rofessloal SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION - - SPECIAL CIRCUIT/M19C
7Fp, therebyafil.that IamexemptfromtheContrator'sLicenseLawforthe p T) T E
P following reason.(Section 7031.5,Business and Professions Code:Any city or 'v f -
O z^ TEMP.METER OR POLE INST.
countywhicII turepi ulrnapeus.x,tto construct, sthemprovgdemoBeh, er ttr h c
.aa any atacturc tatementa that
he iaabo sed pursuant
t the revu ons of it a POWER DEVICES
V file a accord statement that he R licensed pursuant to the provisions of the TE
Oc: Contractor's License Lew enfickoesCodChapter 9 menclng with xSection
mptthe00)of andivi. VALUATION
Or^ BWIvfhRNG I1�OL EI.ECIRIC
3 the basis
and exemption. Any vimthathe V Seem 7031.5 by and
g yd$ the baai.for the alleged exemption. Any violation of nation 70)1.5 by any OUTLETSSW ECHPSHKfURES
applicant for a perMt subjects the applicant to a dull penalty of not more than
o five hundred delta.(S500). NEW RESIDENTIAL ELECTR_SQFf. STORIES ••TYPE CONSERUCTION
I,as owner of the property,or my employees with wages as their sole
compensation,wBldo the work,and thestmelure Is not intended or offered for
J O
sale(Sec.7044,Business and Professions Code:The Contractors Llmme Law
Iil�S. does not apply to an owner of property who Wilds or Improves thereon,and
r-5^ who doessuch work himself orth rough his own employees,provided that such OCC:GROUP RIS.UMTS
Improvements are not intended oroffered formic,If,however,thebullding or - TOTAL:
improvement[sold withinoneycarolcompIction,the owner-bullderwlll have ,`
tI3£��rden of proving that he dldnot Wild or Improve for purpose of sale.). QTY.q"• „),;PLUMBING-PERMIT' r;,'! ?FEE FLOOD LANE APN
LJ 6 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE / M
contractors to cankrud the project(Sec.7044,Business and Professions Cade: W -
The Contractor's License Law doe,sat apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon,and who contracts for such pkojects with a �`, s 1
��I,EactoKd Licensed pursuant to the Contractors License Law. FEE SUMMARY
Ll1 am exempt under Sec B& P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y N '
Owner Date RECEIPTM
t� '0WORKMAN COMPENSATION DECLARATION HKTURE&PER TRAP d /'I/S SQ{OOL 7A% Y N
I hereaffirm that I have a certl0ate of consent to eel(-Inmrc,ora C aKJ RECEIPT N
moo,Lab C.I
ceeifimteofWorkeri CompemaHonlmuranmoramtlfled ropythereof(Sec, - CAS EA.SYSTEM-1 INC.4OUTLETS - PARK pI� ' Y N
Policy M - GAS EA.SYSTEM-OVER 4(EA) RECEIPT p
Com any R UILDING D I VISION FEES
�Cedtfied copy l9 herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Wl r filed copy b filed hereby fu the ed.lnspettion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XIOFT. Date Reml t# '
(rhissectlon need not hecomplekd If the permit ti forone hundred dollars
(E1M.siess.) ENERGY FEE Y N
Icertilythat inthe performance ofthework(orwhichauWATER HEATER W/VEM/ELECTRthls peonitlalsed, / W
I shall not employ any person in any manner w as to became subject to the WATER SYSTEM/TREATING
workers Compensation Law.of Califinau. Date PAID
-
Z Z Applicant NEW RESID=- AL PLMB, SQ.Fr. Date Recei t#
_Z O NOTICE TO APPLICANT:If,after raking t his Certificate of Exemption,you
should bcmene subject to the WorkerY'Compeneatlon provialna of the Labor - TOTAL:
F N ' Cod,you at[of hwith comply with such provedoes or this permit shall be '
W C deemed revoked. _ BU ••E .
dCONSTRUCTION LENDING AGENCY _ SEISMIC FEE
Ihercleyafflrmthat there h a construction lending agency forthe perform- ELECTRIC PEE -
7'Z .nceoftheworkforwhichthbperMtblwd(Sec.3097,CIv.C.) TOTAL. 2'• PLUMBING PEE Qp
V O Lender'.Name '
LL F Lender's Adden. QTY. 'MECHANICAL PERMIT' -,`BEE MECHANICAL FEE
OW I cotlfythatl have read thuapplic tion and sonthat theabove Information
IL beemt.I agree to comply with all cityand muntyordlnances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives ofthls
city to enter upon the abovcmrntimmil property fee Inspection purposes. ALTIRORADDTOMECH.
Z :
V Z (We)agree to save,indemnify an d keep harmless the City of Cu pert Eno Date ReCelpt#
against liabilities judgments,mats and expense.which may In any way accrue AIR HANDLING UNIT(1010,EW CFM) - SUBTOTAL:
again Ed City In n quenre,o the granting of this permit. AIRHANDLING UNIT(OVER 10,W0CFM) CONSTRUCTION TAX .
(/ CONSTRUCTION TAX PAID:
Signs rcol ApplHAZA DOUSor Date IXIIAUST HOOD(W/Df/Cn
HAZARDOUS MATERIALS DISCLOSURE - s
Will theapplianI or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RECCE t#
reatc,Ld as defined by the Cupertino Municipal Code,Chapter 933 and the - �.aak
Health and Safety CIA tion 255324)7 - HEATING UNIT(OVER 100,(.00 BTU) - TOTAL: W
17 ye. 9No -
Willtheapplicant orfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE BESIDE �.1�^S�'IANGE DATE .•
which rout hazardous air contaminants as defined by the Bay Area Air
Quality Management Distinct? - BOILER-COMB'DEEP OR 100,0W BTU)
Yrs No JUN
Thavereadtheha arousmaterialsrequirementsunderChaptei6.95of BORER-COMP(OVER 100,000 BTU)
the California I'lealth&Safety Code,Sections 25505,25533 and 35534. I
understand that if the buildsng does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.. ,
responsibility to orally the occupant of the mqulrement.which mussstt�be
Edo
to once of Ce Ifl to of0 panty.
Asri
Ownerorawhotizedagent Data - - ISSUIeD BY:
TOTAL:
' OFFICE COPY