21794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Addm
10 11:1, 0, Wo�-F �-c�. 21794
Name one: A A A
ner, ( �k,— CITY OF CUPERTINO BUILDING DIVISION L
Comradoe,Name: a IILk.N. APPLICATION / PERMIT J 1. la1n
'Sf�✓j"�SC/J O Y Z BUILDING-ELECTRICAGMUMBING-MECHANICAL CA'TEG'ORY
mhltect/Faglneer. Lic.No: VvJ
/ �� G_«tom QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 2��Xn.J,to Qfl}- �K PER ITISSUANCE ❑ El
CONTRACTOR'S DECLARATION
I hereby.
that l am Bcmxd under provtslons of Chapter 9(commenc APPI.IANCESRRSIDENHAL OBDFSCKU-110N
Ingwlthsection 7000)of Dwlslon3ofthe Busiresnand Profe stonsCode,and my
license 1,in full forte and effect. PANES � � L•�
Llcenx Cla„_M_Date
C.rot
ARCHITECT'S DECLARATION MI-1000AMPS
O
C Cl understand my plans shallbe used as public records. OVER 1 ODD AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
(0 Licensed Profoask al SIGNSELECTRICAL
Q OWNGR-BUILDER DECLARATION SPECIAL CIRCUIT/MLS( '�O
7 tp.z Iherebyaf(Irmthatlamexempt fromthe Contractor's License Gw(a the t
OgFQ following reason.(Section 7031Z,Business and Professions Code:Any city or TEMP,METERORPOLEINST.
5� W countywhichrequlmsapemNttommtmd,alteglmpmv dem lB h,ormpair
GF C5.�i anyetmdum prior to Its Luuance,also requlrestheappllcaut forsuch permitm ppyyER DEVICES
a K }V file a cies ed statement that he b Ilmosed pursuant to the provisions of the
�3ec� Contrador's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O sion 3 of the Business and Profe„Ions Code)or that he b exempttherefrom and
t, 5 the baals for the allegedexemption. Any violation of Sedio7031.5 by anyOUTLE3SSWITCHPSFIXTURES U' Q Q d O
applicant for a permit subjects the applicant to a civil penalty a not more than t
live hundred dollars(S500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPB CONSTRUCTION
F11,as owner of the property,or my employees with wages as their sole
compensation,wllldothe work,andthe structure b not inteaded or offered for
,J sale elec,70K Business and Professions Code:The Contractors License Law
qs$ does not a pply to an owner of property who Wilds or Improves themem,and OCCGROUP RES.UNITS
who does such work himself orthmugh hisownemployme,provided that such
Improvement,am not Intended oroftered forsale.If,however,the Wilding ve TOTAL:
Improvem,nt Is sold with[none year o(complMlon,the owner-bullderwill have
t"rden of proving that hedid not Wild orlmprove forpurposeotsale.). QTY. PLUMBING PERMIT FEE FLOOD MINE APN
L L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor's License law does not apply to an owner of property who
Wilds or improves themes, and who contracts for such plojecis with a ALS-DRAIN&VENT-WATER(EA)
yS(actor(s)Brensed pursuant to the Contractor's License Law. BACKFLOWTfL
PROT.DEVICE FEE SUMMARY
U 1 am exempt under Sec B k P C for this reasonFFSOUTSIDE F
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner
Data RECEB'T#
WORK MAN COMPENSATION DECLARATION FIXNRFS PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that 1 have.artlRate of consent to sell-Insure,ora RECEIPT#
artifiateofWorkers•Camperuatlon Insurance ora certified copythereof(Sec. GAS EA.SYSTEM-11NCAOUTLEfS PARK FEE Y N
3800,lab C.) IRECEIPT X
Polley# �f t roSS 3 —GU
Com any ate.-,-n:TM C� GAS-FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
�ceni0ea ropy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHGCK FEE
EQFeRlfied copy Is filed with the cityinspection division. it 7
CERTIDCATE OF O(EMITION FROM WORKERS' GREASETRAP PAID ,, LL
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA NOELDate ReC I t# 7"1K
(Thlssectlon need not M complcted If the permit 1s forone hundred dollars
(810(ass.) WATER HEATER W/VENT/ELECTR ENER \
1 artifyrtBytha In the perfomunceof the work for which this permit is Issued,
1 shall not employ any person In any manner x as to become subject to the WA70(SYSTEM/TREATIN'G LJ
Workers Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. ` ate R Cel t#
Z O NOTICE TO APPLICANT:ILaRer making this Certificate of Exemption,you
should become subject to the Workers'Compereatlon provisions of the Labor TO AL:
F N Code,you most fort hwith comply with such provisions or this permit shall be BUILDING FEE
j deemed revoked.
LU a CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby aBlrmdut there is a construction lending agency for the perform- TOTAL; ELECTRICFEE
Z anceotlheworktorwhlch this permit is Issued(See.3097,Civ.C.) PLUMBING FEE
02 lender's Name
LL ~ landereAddm,a QTY. MECHANICAL PERMIT FEE MECHANICALFEE
Wt lanlfythatlMvereadthbappllotlonandaatethattheaboveinfomutmn
O
1 hcormlagrceto comply with all city and county ordinances and sate laws PERMIT IENUANCE FEES PAID:
relating to building construction,and hereby authorl,m representative of thts
F Z city to enter upon the aWve-reartionad property for Wpeslon purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnity an d kap harmless the City of Cupertino Date R cipt#
V against lhb111tie,judgments,mss and expenses which may In any way accrue AIR HANDLING UNIT ITO 10,ODOCFM) SUB OTAL:
agal said City m ,egnmmonhe granting of permit. CONSTRUCTION X
. _ AIR HANDLING IINIT(OVER I0,000CFM)
Slgruturcot Applimnt/Contractor Date EXHAUSTHOOD(W/DUC'D CONSTRUCTION PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bull,ingoavpant store or handle hazardous HEATING UNIT ITO 100,000 BTU) Date RCC t#
material a,defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code t±S�-Stection 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTA • 12G.70
❑Ye 046
Will the a ppllcaut or farm re building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haeardom air contaminants as defined by the Bay Area Air Id0[LFR-COMPOHP OR t00,IXD BTU) P/,�D
Quality Ma�ugemcnt District
4 Yns o p
haveria Health
car Safety
node,Sections
255nb5533 and 25511.
of BOILER-COMP(OVERl00,W0 BTU) V u 1pe1
the Califunderstand
t Ha the b Safety Code, et Curr ntly have
a to rad,that 1 r k.. C Dal
understand that ltthebullding docs not currently have atenanL that It NEW RESIDENTIAL hfIiCFi. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
pri Issuance Wa rtlticate of Occupancy. 012niaaatcup lffA
Owner or authorized agent Date ISSUED BY: �Y �r� '
'IOTA L:
OFFICE COPY