21127 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY �—g"- Z
Building Pm ert Identification 17 PERMIT NO.
Building Address:
� 6 Vo PLAu �ac2�v) 21127
neve ams: T'��� �n one:
(—Qy(� CITY OF CUPERTINO-BUILDING DIVISION
• c Mr.
2.N.me: Lic. e: APPLICATION / PERMIT 1
021> Q BUILDING-ELECTMCALPLUMBINGM[CHAMCAL CATEGORY CONTROL t
Arch
Lic.Net
MC �G QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby
h,%di-bmthat lam llcensedh.War B.9ams.ndprovisions o(ewdonsr9le,and y AI'1'LIANCFSRESIDENTIAL JOB DESCRIPTION
Ingwith$MIon7000)ofDivlelon3 afthe BuMnsssand ProfeaslonsCode,and m
limns le In to
o and effect PANELS �1
l
Lia Pyla LLCM .r
Date Contractor
ARCHITECTS DECLARATION 201-100IAMPS
q�q�uu mO zp lundentand my pins shall be used upublic recoNe. OVER 1000 AMPS SQ.FT.FL FA §/SQ.Ff.
6e Licensed Professional SIGNS ELECTRICAL ( � 80
<<�< OWNER-BUILDER DECLARATION S['ECIAL .1
7s, � IhombyaNrmthatlame.reept frornthe Cantmelm.0 nse law Jostle
O F. folbwing recur.(Section 70115,Business and Professions Code:U City er p M OR E
county which requires a permit to commud,alter,Improve,demolbh,orrepalr
a. a nystm=mpdortoi"ba�.ncl.bo quireath.appUun•for.uch;,Ip,.. ppSygRD
fil...lgid statement that he b licensed punusnt to the pmvblons of the
3u, Contracts,'.License Law(Chapter 9(commencing with Section 7000)of Divi- gWP4.UNG C
F,�OS Mon3o(the Buainessand Pre—es Code)orthathebemmptihemfmmand VALUATION
S" the basis for the alleged exemption. Any Violation of Section 7031.5 by any s BO
< applicant for a permit sub(cbthe applicant to a civil penalty ofnot marc than OUTLETSSWITCHES-FIXTURES
five hundred dollar.(§5W).
�n ❑[,as owner of the property, NEW RESIDENTIAL ELECTR SQ}T. STORIES TYPE CONSTRUCTION'
p perty,or my employees with wages as their set
compensation,will dothe work and the structure is net Intended or offered for
p vole(Sec.7054,Business and Professions Code:The Contracoes License Law IM—Sa
$$ docs not apply to an owner of property who Wilde or Improves thereon,and OCC.CROUP RES.UNITS
whodoessuchwurk himself orthrwgh hlsownemplgeee,provided that such /t
Improvement arc not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement bsold witht one yearn(completion,the owner-bullderwlll have
tIBLIlurdeno(perving that he did not Wlldorlmproveforpurpoaeofaale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LLff I,as owner of the property,am exclusively contracting with licensed pp-RMIT I55UANCE I"�
contractors to construct the project(See.7054,Business and Professions Code: (',�
The Cent moor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wthereon,
builds or Improves and who contracts for such p(ojets with e
ott[ator(s)Iimnsed punuanttotha Contrador.Llcense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• OUTSIDE FE�LS
Owner Date RECEIPT It
WORKMAN COMPENSATION DECLARATION MTURESi PER TRAP SCHOOLTAX Y_ N
❑e hereby affirm that I have o Insurance
ra c of consent to py thereof
ora RECEIPT Y
380lfirab o(Worken'Compensatlonlnsunnce oracertlfled copy tM1emo((Si. GAS EA.SYSTEM-1 INCAOUTLETS PARKIFR Y N
350Q ab CJ
Clorry N GAS EA.SYSIPMAVFR 4(EA) RHC I=. N
ny BUILDING DIVISION FEES
Certified copy b herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy b Ned with the city Inspection division.1
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID 77^^
COMPENSATION INSURANCE SEWER-SANITARYSIORM EA 200Fr Date Recei t# I ]yw//��s,r,,
Qhteetlan need not be complMed If the perrtdt t(Drone hundred dollars
(s1I ordify that
WATFRHEATERW/VENT/ELECTR ENERGYFEE Y N
(certify thato the person
any
rohe work fare,to become abject to the WATER SYSTPM/TREATING
Wom'Compenaatlon Laws of California.lfrrnla.Date PAID
O Z pil NOTICE Date Recei t#
_Z O NOTICE TO APPLICANT-.If,cher making this CertRESIDENTIALle o(Fxemptlon,you NEW RESIDENTIAL FILMS. SOFT.
should become subject to the Wmiteri Compensation previsions of the Lshor TOTAL:
P @Code,you=at forthwith comply with such provisions orthls permit shall be S
Cr j deemed revoked.
-DU1NGFEE
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE I
Z Iherebya(firmlhat there b a construction lendingageney forthe perform ELECTRIC FEE Q
7 anceofthe work for which this permit is TOTAL:issued(Sec.3097,Clv.C.) r
C) O Lender.Name PLUMBING FEE O
LLI— Lreder.Addrom QTY. MECHANICAL PERMIT FE6 MECHANICAL FEE [( Q
O W ImAi(ythat l have read this application and statethattheabove Information
tcorred.I agree to complywlth all city and county ordinances and Mate laws PERMIT ISSUANCE /2c,00 FEE$PAID,,
} IL relating to building construction,and herebyauthoriae representatives ofthi,
(— N city to enter upon the above.mentloned property for inspection purposes. ALLERORADDTOMECH.
? (We)agree to sav Indemnity a d keep ha ass the City of Cupertino Date Recci [# Qt�
C) against liabilities,' gerentgco nd exile hlch ymanywaya AIR HANDLING UNIT CTO 10,000 CrM) SUBTOTAL.
against conseque Athe it permit.
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
of Ap onus r IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATH RDOUS MATERIALS DISC SUR
Will the KA
or building occupant store or handle hazardous HEATING UNIT(TO IOO,DDO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
I Icalth and Safety Cade Suction 25532(x)7 BEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ya r!No
Will the applicant orfuturc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS AT �,fY�
which emit harardous air contaminants as defined by the Bay Arca Air a
Quality Management District? BOILER-COMP QILP OR 100,DM BTU) 1 1991
4Yes �No nPD
have read the bazar nus materials requirementunderChapterli,95of BOILER-COMP(OVER100,000BTU) APR
the Czlifomla Health k Safety Code,Sections 25505,5533 and 25534. I
understand that ifthebullding docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT pp(( 441,ra,,, -s
responsibility to notify the occupant of the requirements which must he met us
prior to issuance a a Certificate of0ceupanry. d N
Owner or authorlud agent Date Imo.
TOTAL: ISSUEDBY�tI�Ulll./iJn/—ate
t'�J V
OFFICE COPY