21625 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES = USS3GE BALL POINT PEN ONLY
BuildingProject Identlfkatlunot PERMIT NO.
S Building Add.: 21 6f15
g w eF�p �u` cc�v�T Q � CST G I �h/G
came: meA A
p &VOLR I.tiT-Mjr-_400 CITY OF CUPERTTN6BUILDING DIVISION
Contractor'.Name: Lie No APPLICATION / PERMIT
it rF3-I-t3o BIIRDINGFd.EC(WCALILUMBINGM HANICAL CATEGORY CONTROLI
ArchBeci/Engineer. LJ No:
daSSFJpI Pty l p L C V QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am Bcmaed underprovhion.ofOaper 9(mmumnc APPLIANCFSIRF_SIDENTIAL 108 bEscRipTriwN
Ingwlth5ectbn700mof DIWNon3ofthe Bud¢s,avd PmfeW on,Cade,and
IlcemeCnfuB/om,nd dfect. -3OC�1 PANE bFQw�--
LkmnxClaa 1� Li I
Date Contractor UP TO 2DO AM15
ARCHITECPSDECIARATION 201.1 M AMPS
p�p�uuntCZC I understand ed m
my plana shall be uaas public¢ rda. OVFRICCOAMPS SQ.FT.MOOR AREA f/SQ.IT
k o U L o rued Prdmbrul SIGNS EL.EC RKAL
QQOWNER-BIRLDER DECLARATION gr[ICIALCIRCNT/M6C
z b Thereby dfirm that l vneaempt from the Covtra or',Lk ,n Law for the
following reason.6eClon 7015,Bushes and Profmbro Code:My city or
O TEMP.METER OR POLE INSP.
FSI c ystm hkhtequlr iUp a=eaco mutt,altLheaprovgdemmch,mrrept
eny atmctun pMtoltahu,ncga mnwd urviant to th tf¢wche,of t e POWER DEVICES
c. Bk a algnr'sstatement that ha h 9(cpm encing with
the pro700D) f the
Contractors utdri Law(Chapter9Commencing wdh Section700.of Divi- SWIMMING POOL ELECTRIC F, ,bn3o(thc BuMm,rad Pmfmbro Code)orHut hekexempt Ihercfromard VALUATION
S" the bash for the alleged eaem ptlou. My oblation of Section 7015 b/anyI OUILEISSWHCIfi1:SFT%TURES q�)
appIlant for a permitwbjeea the,ppibant to a civil penalty d not roo¢than
r. °B nv�, ..dre i ddha(scam.
L�1,e,o r of the property,or my crtployen with wage u thdr sole
STORIES TYPE CONSTRUCTION
C a • Pens'tion,wBldot , tructurchriotWWedoroflemd for
❑ s1.be 704Ba.ratandi P .Iore;Cod'.The Codractars LI¢ror Law
{ S� doa not applyban owm dproperty who build,orlmprwetkrcoR and
c- whodae.uch work hlmaelforthme
ugh hl.ownempluye ,provided thatsuch OCC.CROUP RES UNITS
Improvement,arc rot Intended oroffered for sak.If,h¢vever,the Wilding or
h /� AL
Improvement wld whhlnoneyearofcompfetbn,theovooer-bullderwiBhctve
TE
t rdendp,odngthAhedwnet Wild m improve!¢prpose ofak.). QTY. PLUMBING PERMIT FEE
1,a owner of the property,am erchulvely contracting with licensed FLOOD ZONE APN
contactors to comtmet the pmIed ESr 7014,Beteomand Pmfmbro Code: PFRMITISSUANCE
The Corumdor'a Llceroc Law doe not apply to an owner of property who ,LLiFR DRAIN&VENT.WATER(FAT
or Improve Mneon, and who contracts f¢such p�peaa with, FEE SUMMARY
1%liedoa
(s)Hamd punoom to the Contn ¢smn
ciLln Law. BACK FLOW PROTECT.DEVICE
LJ I am eemp under Sec B&P C for thio noon
OLUSI DE FEES
Ownrr Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
WORKMAN COMPENSATION DCL
EARATION RCCEBT 9
❑I hereby affirm the I FIXTURES PER TRA SCHOOL TAX Y_ N_
have a¢rtlf{ute d consent to stewrc,¢a -
ceM1lOof Worken'C¢npewtlan Irounn¢¢a certified mpythemef(Sec. RPCFBC g
Lab
38O,Lb CI CAS PA.SYSTEM-1 WC40I11I.EfS PARK FEE Y_ N_
RECEC.
Y GAS EA.SYSTEM-OVFR4(EA) BUILDING
DIVISION FEES
CenNed mpyhhercby fumlahed: GREASE/INDURL WASTE INTERCEPTOR STPLANCHECK FEE
eM1Ned copy h(Tied with the city Iropettbn dlvW on. '
CERTIFIUTE OF EXEMPTION FROM WORKERS GRFA-SETRAP
COMPENSATION INSURANCE ePAID
(1hlactbnneedn¢hcompleed Bth ,mUthfaonehundrddallanSEWER.SANITARYMRM EA Dale Repel tPT
so
(fl Omarfes.) WATER HEATER w/VFNr/ELECTR ENERGYFEE Y N
I¢rtlly thatbthe pedomun¢o(thewceklorwMchtM.pemdthbmeQ i
I slug not employ any person In any Runner an et to become subject to the WATER SYSTEM/.TREATING
Wokeann Compenutbn Taw,of Cahfomh. Date PAID
O Z Appllt
-Z O NOTICETOAPPLICANT:B,altrr mating thh CertBlate of Exemptbn,you NLw 12mOF3gTIAl PucB. SQ=. Date Recei tll
. old becorre subject to the Worker Cornperoatlon provisions of the Labor TOTAL
cc N Code,yen.9forthwith coWb
comply with each prov m thio t permshall he
] deemed revoked. III ITT T717 clr
p CONSTRUCTION LENDING AGENCY S I M FEE t
CL Iherebyaffirmtlut therchamrotructlon krdingagerery fortis perfortm ELECTRIC FEE
D Z a n¢oftheworkforwhbhthb mtlthhmud(Sec.3097,CN.C.) TOTAL.
U O T,ender.Name T PLUMBING FEE
U. F- T,ender.add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W a
I ally that l have read thh,pp"flon and Aatethattheabove Information
11 Iemrmt.I agreeto comply with alldty and countyordhunm and sate laws PERMIT ISiSUANCE FEES PAID:
>. Mating to Wilding comemctfon,and herebywthartureprca ¢
entelyofthh,
F Z dtytoenteruponthe,bovcrrcntbrcd propertyfolropeCbn purposes. ALTER OR ADD TO MECH.
(We)agree to ave indemnify an d keep hamdm the City of Cuprrtino Date Rmci tit
V agaWtllablBtka,�udgnrms,co+taand a pen.whTchmyEnanyway..,, AIRHANDLING UNIT(fOl0,o)OCFM) SUBTOTAL:
age Wt old Cky b mns�uena o(the grarding d thin pertnit.
MR HANDLING]INrr(OVER 10,000CFM) CONSTRUCTION TAX
Signatu A)Jpuant Can �mk -}1 1 el IXHA[h7 HOOD(W/DIRT) CONSTRUCf1ON TAX PAID:
HAZA RDOUS MA ERIALS DISCIA URE
WOlthe,ppBant¢futurt Wliding oavpant,torc or haMlehvardous HEATING UNIT(TO 1O,000 B'ID —Date Recei tH
material as defined by the Cupertino Murddpal Code,Chapter 9.12 and the
vp
Hearth and SafetyCod,Scai.25532(e? HEATING UNIT(OVER 10,000 BTU) TM
AL No
Will thr applicant or futum Wilding o pant use equipment or devim VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
which emit haaardous air conlamW nts a,defined by tie Bay Area Ab
Quality Management District? BOIIRR-COMP OI-R'OR 10,00 6T[q PSR®
Yn ❑F�No
have read the havr..muterlab requirements under Chapter 6.95 of 11011-ER-COMP(OVER1 O,0O BTU) '1 �t
the California hdbFEB 1
ealth&Safety Code,Sero 75505,75533 and 25534. I 4 1991
uMastami th,tlf the Wilding don not mrtently have atenanL that lthmy NEW RESIDENTIAL MECH. SQFP
rnporoBeWty,to notify the occupant of the requirement,which must h met
primtot ante of a Certificate ofoccupancy.
ON pf n11nt•. .-♦
F t
Owner or Ruth agent to
TOTAL ISSUED BY:
OFFICE COPY