21577 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN O
Building Proea Identificatione. ��/(J],� PERMIT NO.
Building Address: 215 7 7
a rr0 c D
nere roue: - one:
1nA �Q�'y CITY OF CUPERTINO-BUILDING DIVISION
c°^ M°r'a me: / LIc.Na APPLICATION I PERMIT
/`� &SWFBUR.DINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL p
rc ItM/Engineer, Lie Ne:
QTY ELECTRIC PERMIT FEE BUILDINGPERMITINFO
Address: PERMITISSUANCE 1:1 1:111LICENSED CONTRACTOR'S DECLARATION
Ihereaffirmthatl amlicensed orderChacmme- APPLIANCESREADENTIAL JOB DCRE''UON
Ingwlth Section7000)ot Division ofthe Buainessand ProfeaeomCDde,and
my
I i^In ro�J{(¢eo fid ,.I lT�� PANEI2
Llcen Cl. Cid- Lli p 0 W
Contractor
ARCNITE SDECLARATION 701-7000 AMPS
m'ZO Iunderstand my plamshall be used a publIc records. OVERIOOOAMPS R $/SQ.FT.
t Licensed Professional SIGNS ELECTRICAL COMPUTER
�< OWNER-BNLDER DECLARATION
7 y,�4 1 hereby alfl mthat I am exempt from the Contractor's License Caw for the SPECIALCE2CIRT/MISC
pp (allowing reason.(Section NSIS,Business and Profession,Code:Any city orcou //� �'
renaTEMP.METER OR POLE INST.
p� any tmhlm prorltaipi ncroaloraNimth,imptove,demoWh,eor mpto
any atruRure tateme t hat hr la licensed
purme t to thet(orauch at of t e POWER DEVICES
(e (g
file a signed statement that he h Ilmneed pursuant to the provlslona of the
Ow Contractor'sLicense Law(Chx Fur 9(rommendng with Section 7000)ofDivi-El sion 3 of the Business and ProfesslonsCode)or that he h exempt therefromand SWIMMING POOL ELECTRIC / VALUATION
Gthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSFISWITCHESVIP D� Oa
p applicant fora permit subject the applicant to a civil penalty of net more than TO
five hundred dollars(S50O).
I,as owner of the property, NEW RESIDENTIAL ELECTR_SQIr. O IYPECONSIRUCTION
7< ❑ p perry,or my employees with wages r thele door
compensation,Bwill do usiness work and the s CoderchnMIntended oroffered for
M dole(Sec.ot ppy Businessandproperty Code:The Contactors License
ar Law
sees oessucly torn ownerofprough his wnemsoelmpromes ovidedreoryand OCC.GROUP RES.UNITS
GG
who improvements
am khimself edorwgh hleownemp,hcxty verotheedthat gor
improvement arc not Intendedoerofco Torsion.ILhowevepadbler ill have TOTAL:
Improvement bsold wlthinoneyearofcomplMion,the owner-bu0derw111 have
tl"mrden of proving that he did not build or improve for purpose of dale.). QTY, PLUMBING PERMIT FEE FLOOD LONE APN
u L as owner of the property,am exclusively contracting with licensed pp (yy)�UAFJCE
contractorsto mmlruct the pmjed(Sec.704y Business and Profeuiora Code:
The Contractor's License Lw does fiat apply to an owner M property who ALTER-DRAIN AVENT-WATER(RA)
builds or Improves theater, and who contract for such pPjects with a
cgR(TaMor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
U I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE QIITSI DE FEES
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N
. Owner Date REC[2Pf p
ORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y_ N
J!dnsreby orke that I have• l mu an of consent m self-Ineure,ora RECD,p
ce00,La eC.Workea'Campewtlonluurance oracertlfled cagy thereof pec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab CJ .
Policyp 6[/C /d 78'03 GAS EA.SYSTEM-OVER 4(EA) — RECEIPTX
Com anv �' Le-. BUILDING DIVISION FEES
�CertJfJ d copy is hereby fumldhed. CREASE/INDUSfitL WASTE INTERCEPTOR PLANCHECK PEE
TTI GeWE ropy h filed with the city Inspection division.
V CERTIFICATE OF EX0xlff(ON FROM WORKERS' GREASETRAP PAID
-
(Dissection
SEWER-SANITARYSTORM EA 20OFT. Date RCCeI t#
(Thbzectlan need not be complMed lithe permit h(Drone hundmd dollars
(4100)orleu.) WATER HEATI]4WNFNT/ELECTR ENERGY FEE Y N
readily that In the performance of the work forwhich this permit is Issued, —
I shall not employ any person In any manner so ex to became subject to the WATER SYSTEM/TREATINGWorkers'CoenpenuBon Laws of Gmh
llto .Data PAID
O Z Applicant NEW RESIDENTIAL PCMB. :OFf. Date Remi (#
Z O NOTICE TO APPLICANT.if after ma king this Certillateof Exemption,you
should become subject to the Workers Compematlon provisions ofthe Labor TOTAL:
N Code,you muat forthwith comply with such provisions orthh permit shall be
j deemed revoked. — BUILDING LTE
CL Cv
CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby affirm that there is a con,wctlon lending agency for the perform ELECTRIC FEE
7 Z ante ofthe work for which this permit is Issued(See.3097,Civ.Q TOTAL:
V O Lenders Name - PLUMBING FEE
IL H Lender,Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfy thatl have read thhapplialionand state thaltheabove Informationa hrorrect]agree to comply with all cityand munty ordinances and state laws PERMIT ISSUANCE FEES PAID:
r W relating to building construction,and hereby authorize representatives ofthh
Z city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADDTO MECH. Date ReCei t#
— #l51l1cfc
/odove,Indemnify an d keep harmless the City of Cupertino Jodgmentd,roots and expect hl may In anywayacceue AIR FIANDLINC 11NTT(TO 10,000 CFM) SUBTOTAL:d, coLjQf lhe/gr/anlln spermll." //V a 17�/ AIR HANDLING UNIT(OVER IO,OW CFM) CONSTRUCTION TAX
Sinature of Applicant/Commeffir ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies fit or future building occupant store or he ad Is hazardous HEATING UNIT(TO 100,000 BTU)
acted.)as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the _ Date Rami tit
Mea ith and Safety Code ie51SS37(a)I HEATING UNIT(OVER IOg000 BTU) TOTAL:
❑Yrs I No �}Is4�
Will theappllcaat or turn building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS (U TE
which emit hazardous air cocams,de0ned by the Bay Area Air ms's r'
Quality Management Dist 7 BOILER-COMP(3FB'OR 100,000 BTU) � ��
4Yes No
have read the h ous materials requirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU) �i3y1
the California Health k Safety Code,Sections 25505,25533 and 75534.1
understand lityto fthe ifytheocn piissnMcurrently have
- my NEW RESIDENTIAL MECH. SQ.FT of
aibllily to nMlly the ocmpantofth dol menta which must be mol M
p ° to Wua ofa CertlO c Otte a G r��.4sp�N�p
nor or authorlud agent Data
/�
TOTAL:
ISSUED BY•\J LlrpY
OFFICE COPY