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21105APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 07 -,S -- Building Project Identification BX 0 '4,a1- Vo I d 0 s R PERMIT NO. 21105 wnere ana: one: _d-8 NZ &Raulp CITY OFCUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUILDING.ELECTRICAI.PLUMBING-MECHAMCAL rate 'eN ma•Lk. Na: N a G � o CATEGORY CONTROL X Archil /Engi k o QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO ® S51 I.CI Address: PERMTISSUANCE Q7 LICENSED CONTRACTOR'S DECLARATION Thereby affirmlhallamikrnsed under provisions ofChapmr 9 (aimmene. ingwlth5eelan7DOO)of DiW3ion3ofthe Busineaeand Pfad.r.Cocleandmy license lslnft o eandeffect. 6G/ Lima CI Lt.Y bb..5 AI'PI.IANCESRESIDENML )OB DESCRIPTION �cD'1'� T-' K.1 PANES Date Contractor P, V UP TO 200 AMPS 101-1000AMPS ARCHITECT'S CLARATION fundemtandmypiamahagbeuwdwpub0cremrds. OVERIODOAMPS SQ. IT. FLOOR AREA $/SQ.FT. SIGNSELECTRICAL Llcemed Professional ''2'383 OWNER -BOLDER DECLARATION I hereby a(Orm that Iamexempt from the DECLARATION License Law for the following motion. (Section 7031S, Business and Pro(eesices Code: Any City Or munlywhich require a permhtamngruct, alter, improv, demahsh, orrepalr SPECIALCIRCUIT/MISC 1 a/i/•'' TEMP MITER OR POLE [NST. any structure prior to its bsuame, also requires the applicant forsuch permit to file a signed statement that he b licensed pursuant na to the provlsloof the Contractor's License Law (Chapter 9 (mmmenclog with Section 7000) of Divi- sion 3 ofthe Bustemsand Piefasslom Code) orthat he is exempt therefecmand POWER DEVICES SWIMMING POOL ELECTRIC VALUATION the basis for the alleged exemption. Any violation of Section 7001.5 by any applicant fora permit subjects the applicant to a civil penalty of net mare than O[TILEISSWITCIffSF[%'1'URES / Q -T l 71 NEW RESIDENTIAL ELE-CTR SQ.FL five hundred dollars ($SD9L ❑L as owner of the property, or my employees with wages as their sale U .G.. STORIES TYPE CONSTRUCTION compensation, wllldolhe work, and the structure ism Intended or offered for sale (Sec. an and Code: The Law to ow doseoe nor apply roanawmr o(p rough whoWild. applyf propertyor improves emorimproovided eoMand whodoessuchwork himself arthrwghhisown employees, provided that such OCC.GROUP RES. UNITS Improvements are not intended oroffered tarsale. If, however, thebuilding or Improvement istalld withinoneyearofcomple0on,the owner-bullderwlll have tFtR)rudenofproving that he did rat bund or Improve fm purpose ofsak.). LLff L as owner of the property, am exclusively comeacting with licensed contractors to construct the project (Sec. 7044, Business and Professions;Professions;Code: TOTAL:71, SO QTY. PLUMBING PERMIT FEE PERMIT ISSUANCE ,et,e �-( J FLOODZONE APN The Contractor's License law donet apply to an owner m property who e builds or Improve thereon, and who contracts far such pVjects with a egy(adoKs) Lensed pursuant to the Contractor's Lt... Law. LI I am exempt under Sec- B k P C for this reason ALTER -DRAIN 4a VENT -WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE ETS DRAINS FLOOR ROOF, AREA, COND. 17XIURE4 PER TRAP SANITARY Y N�� RECEIPT M Owner Date WORICNAN COMPaTJSATION DECLARATION ❑ hereby affirm that I have a ertlRcale of cammnt to .sure, or mrtlfkaof Workers'Compenaalloninaunna oracertified ropypy ththereof (See. 3300, Labb Cd SCHOOLTAX Y_ N_ RECEIPT 0 GAS PA. SYSTEM[ INC.4 OUTLSTS PARK FEE Y N Poll, If M GAS EA. SYSTPM-OVER 4 (EA) Company DINRECEIPT BUILDING DIVISION FOES 11 Certified copy is herebyfurnished.ilm cid. IYJ•Cenl(Ied mpybtllea with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (TNssectionneed not becorepleted ifthepermit bforom hundred dollars GREASE/ INDUSIRL WASTE INTERCEPTOR EGK FEE (CJ PAID Date Receipt GREASETRN' - SEWER -SANITARY -STORM EA. 200n. ($100)orlcnd I rtify that In the performance of the work forwhlch this permit la ised, ca su 1 shall am employ any person In any manner an a to became subject to the Worland Compensation Laws of Cal fomla. Date WAITS HEATER W/VENT/ELI:CTR E•NERCY FEE Y N PAID WATER SYSTEM/TREATING ApplicaNOTICE NOTICE ca APPLICANT: a cher making late Certificate is Exemption, you Code, becomesubject to the Workers' Comp rovisinprovblomofthe Lab or Cade, you moat forthwith comply with each provisions a'tla's permit shall6e deemed revoked. Date Recei t# NEW RESIDENTIAL PLMB.__SQ.Ff. AL; 13UIL ING FEE 00 SEISMIC FEE CONSTRUCTION LENDING AGENCY Ihereby affirm that them b a construction lending agency for the perfare, once of the work for which this permit ls Issued (Sec. 3097, Civ. C.) TOTAL: ! ELECTRIC FE a leadefs Name Lender's Address I certltythal l haveread thbapplicebov tlonand statethattheae Informed. Ismngct.I agree locomply with all city and county ordlnanresand gate laws PLUMBING FEE _ MECHANICAL ' QTY. ECHANICAL PERM[ FEE �T ,�rrys�e� IT ISSUANCE fl c -CJ FEES PAID: relating to bullding mnatmctlon, and hereby authorize representatives of this city to enter upon the above-mentioned property fm Inspection pu �paee� (We) agree m cave, Indemn an d keep harmiess the City of Cupedlno ALTER OR ADD TO MECH. (`p Date Recei t# a�9 _ SUBTOTAL: against llabllfflc rant gsand ex seswhkhmaylnanywayaccru .gaunt Id nruns raceof it. la permit. AIR HANDLING UNIT10,000 AIRFUNDLIN ]ofpD CONSTRUCTION TAX D(HAUS'TH I1CT) /' CONSTRUCTI mtum.f cant/Con actor -SIgO HATARUOUS MATERIALS DISC SD - HEA C 1 , B > - Wlllt e0440 applicant or future building occupant store or handl aaardous materbl act de(imtl by the Cupertino Municipal Code,Chapler 9 2'and the Date Recei t# a T(DY 1 BTI) TO L: IicallhandSafety Code Section 25531G)7 ❑ Yes No Will the eppllmnl or tore building part use equipment devices which cont hacardous air mourmoontsas defined by the Bay Arca r VfN'DLAI' N(SI ERESIU) aIrjraUAA]G Afi .] /•� BOILER -COM OR100,0ffl 11 ) Quality Management District? Y. ❑ No have read the havNno matertab requlremenb under Chapter 6,950 ^ R 1 1991 BOILER -COMP (OVER 100,00 RTU) the California Health k Safety Code, Sections 25505, 25533 and 15534. 1 NEW RESIDENTIAL MECH. SQ.FT understand that if the building does not currently have a tenant, Ihal Ills my responsibility to notify the occupant of the requirements which must be rear prior to Issuance of a Certificate of Occupancy. p ( nnn^ -•-'� 4�1sM. sit so y ISSUED 6Y: ��s^'�lw Owner or authorized agent Dale - L 7175--A TOTAL, OFFICE COPY