21073 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification IPFRhllT NO.
Building Address:
1a ��3 `- k wol>F RV � �°�
' ` 4 21073
one: A
LR GRF}'-r:,L zo(. '12G^4-t Gt-tek CITY OF CUPERTINO-BUILDING DIVISION •Z��t7
Contractor's Names Lie No- APPLICATION / PERMIT I
ifc, CAL CGv`Sf. 33c52( BUILDING-MECTRICA4ML HINGMMIF MCAL CATEGORY CONT$Ojcp�O
Architect/Engin r. Lic.Nex
Qrr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreas: PERMIT ISSUANCE ��
LICENSED CONTRACTOR'SDECON L.�j Z]
I herebyimthatIunder povLnsofChar9( - APPLIANCES-RESIDENTIAL TOO
D
ECHII' ON
IngwlthSdion70 )o(MAsion3ofthegusinandPmfesmsCde,and my
license Is in full fproe N d effect. I PANELS
License lass P'scm N 3 3 G
ate as 1 'R-�Lic.
DorUP TO 2DO AhVS
ARCHITECTSDE 116ION 201-1000AMI'S
Om Z I understand my plans ahall be used as public navrds. OVER 1000 AMPS SQ.E7.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL SQ
�X OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
Z so. I to reby affirm the l am exempt fmm the Contractor's Lix..Low for the r
0 Z following reason.(Section 7031.5,Business and Embrasures Code:Any city or T[MP METO2 R POLE IN1.
F F' countywhich mclulmsa permit toconstred,alter,Improve,demolish,orrepair
`a ..c anytmtvre prl.rmin enerance,ab.requirestheappBcant(..such permit to pp6ypR DEV)
C F U ilk a signed statement that he is Bcenaed pursuant to the prevenima of the
Contractors License Law(Cha er 9(commencing with Section 7000)of Divi-
30�' sbn3 ofthe Business and Profeaslora Cede)orthatt he is exem therefecmand SWIMMING I-0O E C VALUATION
4 Q 5 the basis for the alleged exemption. My violation of Section 7101.5 by any OUTLETS %Tl1RE5
applicant fora permit subjects the applicant to a civil penaltyofnt morethan �QW �� 060
five hundred delta.($50U). NEWRFSID E SQ.FT. STORIES TYPE CONSTRUCTION
FIT,as owner of the property,or my employees with wages as their sole
kX
compensation,willdothework,andthestrutumisnotintereded or offered for
a O sale(Sce.7064,Business and Profeasuoru Code:The Contractors License Law
psi docs not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
w who does such work Wousaforthrough hisenve employees,provided that such
Improvements am not Intended m.ffemd forsale.If,however,thebullding.r TOTAL:_191
Improvement ensoldwithin one yearof completion,the owner-W Bderwgllove
tnLden ofproving that he did not build or improve for purpose.fsak.). QTY, L NGP RMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively retracting with licensed ' IM
dent netors to construct the project(Sec.7044,Business and Professions Code'.
The Crntntrrs License Law does not apply to an.weer d property who gLTFR-DRAIN -WA
Wilda or Improves thereon, and who comet. fm so& projects with aTERFEE SUMMARY
,�t[�etor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEV)
LJ 1 am exempt under Sec B k P C for this reason nOUTSIDE FEES
DRAINSFLOOR ROOF,A ND. 1 G SANITARY Y_ N_
Owner Date RECEIPT N
C31 hereWORK MAN COMPENSATION DECLARATION FO(.fIIRES I'ER.IAAI' SCHOOLL TAX Y N
by affirm that I have a certiRcete of consent to sell-Insure,m a RECEBrF M
cetifiam of Worken'Comperuatlonlre rancemacertlfkd copythereof(Sec. GASEA.SYSTFId- N OUTLETS PARK FEE Y N
3800,1.6 C.)
RLCE PT p
PoI1gN GAS EA.SYSTQd-0 R4(EA) BUILDING DI VI SION FE BS
Com any
Certified copy is heed with the
CREASE/INDU WASTE INTERCEPTOR PLANCHECKFEE
Certified copyenfiled with the citylvpectian division.. a7-
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID �l �,� S�JI3O -T�
/I� {('`��
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 200FT Date Remi t# 8bs}7
(Thissetlon need not be completed if the permit k for one hundred dollars
slm).rl as WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N
re _
I ndfythat In the performance of the work for which this Permit la issued,
1 shall not employ any person in any manner se,as to became subject to the 2
Workerti WATER SYSTLM/TREATING Compensation Laws of California. Date PAIDx
O Applicant Date Recei Iq 50,06
2 nt NEW RESIDENTIAL PLMB. SQ.FT.
Z O NOTICETOAPPLICt tothe,akar makinrs Co thisCertificate
pro is Exemption,you
shwld become subject to the Workers'Compensation provisions of the Labor TOTAL:
~ M Code,you must forthwith comply with such provisions m this pernet.led)be BUILDING E 1 l
W j dmsrad revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE pyx
CL Ihereby afRrenthat there en aconstmction lendlegagency forthe perfmrry TOTAL m ELECTRIC FEE 6 J"'
D Z ance of the work for which this permit enensuod(Sec.3097,Civ.C.)
U O lender.Name PLUMBING FEE Cd
U. P' Lendera Add... QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O I codify thatl have madthis applicaBrnand statethat theabove Information �T
O W 6corred.l agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE 'e.C� FEES PAID:
} a relating to building constmctlon,and hereby authomm representatives of this
coy to entero n the above-mentioned forW ion ALTFRORADDTOMECH. Date Reeeiptq
Z h' Po property he Put sOd
(We)agree to save,indemnity and p harmless the City y Cupertino AIR HANDLING UNIT O'010,000 CFM)
V galmtllabllillea,jud .rents, sat swhkh may In any way acture SUBTOTAL:
aagaiyYt�l (y In nuquen the gr ming.(thio perms
`meg/ tG,3p, AIR HANDWNGUNIT(OVER 10,000CFM) CONSTRUCTION TAX
r
SignT{un of Applicant/Contractor Date IXFLIUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS
- A]ARDOUSOUS MATE RIALS DISCLOSURE
Will the defined b the
rertino Mertipal Code, hhand9.h,and
[iFATING UNIT(TO 100,f100 BTU) Date R¢CCI to
mea Itha as defined by the Cupertino Municipal Code,Chapter 9.12,and the
1 fealth and Safety Codr,9ection 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
r-IYes (Z ' No
ISSUANCE DATE
Will the applicant or tore Wilding oaupant use Nulpment or devices VENTILATION FAN(SINGLE RESID)
which emit hazardous air qrtandeants as defined by the Bay Area Air
. Quality Management Dent n7 BOILER-COMP OHP OR IM,000 BTU)
Y No
havereaIIead azar 1yZtertals Sectionsrequirements 2555,2553 and 25514.
of BOILER-COMP(OVER 100,000BTU) P Q
the
erstanntnhealth building does
Sections 25505,25533 a and75534.I '�C
understand that lithe Wilding does not currently haveatrnan4 that itenmy NEW RESIDENTIAL MECH. `✓Q.FT
respone ibilitvto ntifyth rspaat of the requirements which roust be met r)B " 1990
prior to cou/�6•n<e of
efi�V fOceapancy.
` c��( -7e,_
Y r JJ//1qq1�6yy�pp� pQeamNa��C
n=r.r authodb�g1gTOTAL:
14-v.t Date I OE DOB) BYJ�i
OFFICE COPY