21737 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idendfbtlon L_J T O U PERMITNO.
BuitdingAddrea: 2173 7
\ \ 4'YSS �o V�/o 9Ult_� J�¢ c PLt� Zc `-�
G r 4,rm.oC�1 G.0J S r•C- one. CITY OF CUPERTIN613UILDING DIVISION
Ccetrtcor'.Nanr: Lic.N. APPLICATION I PERMIT \
O U'+"F BUMD1NGkELECIRICALPLUMBINGMECHAMCAL CA=RY - CONTROLIf
Amhltect/Engineer: Uc No:
BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Add. 1'FR)AT N ❑ ❑ a
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam lkm.ed�rderprovblaa of Chapter (cormnnm AI'['I-I JOB Dr.SCRYMN
Ingwlm5enbn 7000)of Dlvlew3eftheBuMrcv dPmfne Code,and OMP T E R
license b In fullfo dfrcL P
LI¢m.e Claas _and LICI 43005 S
Dw
ate CoMrador J
ARCHITECTS DECLARATION 1-1000
p�p�uu 0X R7 1 understand my phm.hall be ural as public rewords OVER 1000 AMIX MIR SQ.FT.FLOOR ARG S/SQ.Fr. .
k 1' Lbenrd Pmf.ional SIGNS ELECTRICAL
G< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Ihereby-flren that l am exempt from the Comncior'.Licen.Lw for the
6$F� following moon.(Section 70115,Buainm and Pmfmbm,Code..Any city or TEMP METTR ORPOLE INST.
rc,4,sy muntywhichrequWaper tomvmM.Jter,improve,demolbh,orrepair
-ny.truGurtprbrmltahatheq.leored Pursuant
t reneasa tto TIER DEVICES
O�� file a stgnM wterrcnt the he b IlrtnaM puroat b the provbloa d the
LL-- b GConuamorb Llcewe Law(C (commencing with Seedon 7000)of Dwi- SWIMMING POOL ELECTRIC
E,30J Yan3ofthe Bueneamd Pmfmloro Code)mthrt heir exempt therefromaM VALUATION
6
..••;7777 teb for the alleged exemption. Any violation of SMbn 70315 m
by y
applicartfora pemdt sub)ed.the applicant(o-dvll pealtydnat mnretlun OUD.ETBSWHCHESFlXNRFS 1 GI I O O O
five hundred dollen%W.
y ❑1,as owner of the property,or oy employees with wages a their win NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONMUCTION
comipewtlon,wW do the work,and thestwdureb rot intended or offered for
a O .ale Sec 7011,BuelrassaM Prdmba Cde The C.M¢d.ea U¢.UA
psi donrot-pplytoaoork hl.w rdpropertywhobuild.orlmprovnth,.,R .d OCC.GROUP RES.UNITS
whodoe,suchwmeelforthrough hisw
onemm
plcy ,provided that inch
Impmvewnb.rt wt intended muttered for .If,however,thebuilding or TOTAL.
Wpmvementbaddwhhimm�yesro(compldbgt owner-bWldmw hove
t"rdenotpmVingthatheald notbu Idorlmpmve(orpurpweofale.). QTY. PLUMBING PERMIT FEE
L L a owner of the Property,-m exchnhxly contracting with Horned EIfJOD ZONE APN
mntrad¢.to mwtaud the pmjed(Sec 7fM1,Buelner and Prdmlom Code. EMIT 1.SSIJANCE
The Contractor'.Lice.Law don w apply to a owner d property who ALTER-DRAIN 4 VERA-WATER(EAI
bunds or Improves thereon, and who contracts for such p�okm wah a
ryD¢+dor(s)Ileemeed puroat to the Contracts.Lt..Law. BACK IIAWIPROTECf.DEVICE FEE SUMMARY
L j I.m e.emM under See. B A P C for this na.on
DRAINS FLOOX ROOF,ARE A,COND. SANRARY Y_ N_
Owner Date, RECEIPT N
WORKMAN COMPENSATION DECLARATION py%,NRF$1'ER.IRAP 54{OOL TAX Y_ N_
F-11 hereby affirm the I have a certificate of emovnt to.ell-Insure,o a
mAffweof Worker'ComptwtlonIaunnceoacemff dmpytherofSec. BBC=4
38(X%tbC.) GAS EA.SYSTEM-1 WC40UMEM mFEE Y_ N
Polley GAS EA.SYSTEM-OVER 4(EA) DING DI
Co my ✓ by Nr PL\ -,(..i BUILDING DIVISION FEES
[eertlned copy b hereby the M. GREASEANDUSTRL WASTE INTERCEI'rOR PLANCHECK FEE
®certlned copy b need with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORME .X%&T. Date Revel til 15-SO
(D)or I.bn nest not M cample[ed dthe permit b(¢one hundred dollen
fn00 WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
I¢KaythVyth ut Nthe pedorwn¢ot thework(orwMch W.p<mdt 1.owed,
T shag mol employ any Peron In any wore,m a to become subject to the WATERSYSIIM/TREATING
worker'Compewatbn laws of Calitomb. Dee PAID
Z 0 NOTICE TO APPLICANT.IL after wking this Certificate of Exemptbn,you NEW RESIDFMIAL PIMB. SQFeoe
T. Date Ri tri
.hould become subject to the Worker.•Comperoatmn provbbm dthe Labor TOTAL:
WHy Cde,ymerrDuff¢thwflhcompywlthwchpmvbbnorthbpermR"lbs BUILDING IL,00
] deemed revoked. FEE
o CONSTRUCTION LENDING wcENcr SEISMICFEE 17-.5 '5
EL I hereby aorkfor w ich this
a mmtmdlan,lice,lingT,, agency Tombs perform ELECTRIC FEE
� Z ace of the work for which this pervJt blwed(Sec 3097,CN.C.). TOTAL: L"i.5�''
V O T<ndm�wme \Ie PLUMBING FEE G,9.se
LL F- T<Mer.Addmy, FW QTY. MECHANICAL PERMIT FEE MECHANICAL FEE V0.541
O W Icent iythat l have reed thbappB¢tbn a M state the the above Information
burin t.lagneg empty muntyordWnmand state lawe PERMIT ISSUANCE FEESIPAID: / (Ys I/ I
} N Mytl erter.l ..the mlmcilan,end hereby wthor lercreber, u'p of this /Ir�t1 Y_I1 �NISL
F Z citto(W)agne to theabnve-mentioned property for WpMbn purposes. ALTER OR AI)D 70 MFCH.
(We)-grtc to ave,IMemMty and Deep hamNm the City of Cupertlw Date RLYCI ted
V agabut liabWtb,)udg nun,cert.andexpenae which may ln-mywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agent sed City In comeque.of the graining of thio permit
AIRHANDLINGUNIT(OVERIo,000CF) CONSTRUCTION TAX
C . T
Slgvture ofA pgant/Contn h to FAFIAUST HOOD(W/DUCT) C�NI$T�2u�ITON TI�X P�11 D:
HAZA RDOUS MATERIALS DISCLOSU E efl-s�l_1'1� —IC_ITLY�b
0000th.apredboe future
pertnoMuniding occupant sortortiM9AZandou. HEATING UNIT(TO 100,DIOBM Date Rccci tit
material as defircd by the Cupertino Municipal Code,Chapter 9.1]•and the
HeahhaM Safety Cde Section 255n(.)? HEATING UNIT(OVER l00p00 BTU) TOTAL: k415.0
Yn T]No
WtheapplhMoruNrebullding.Nntuseaqulpment¢dni. VFNIILATION FAN SINGLE REED) ]Rgl}pAl�-F DATE
which emit hen rdous air contaminant.a,defined by the Bay Area Air
Qua Wy Ma wgement D❑btrkl7 BOILER-COMP HP OR 100,000 BTTJ)
Ihavee ad the haow
vNwledalerequirementsunderChapter495of BOREILCOMP(OVFRI00,000BTU) F. 141991
the GBfornb Health building
Safety re*
etbm 25505,have,
t and 15534.1 '
uMcrdandnat tithelobe louOdNgdoes oftherrennymnts which that it met NEIVRm DFNl1AL MEIN. SQFI'
p.,to ermporaffinityto of notifythef coupof requirements which rrerst be not
prior to Lmmnce daCertirbte D(Ocapanry.
Ownero out agentI Date ISSUEDBY: t
TOTAL:
OFFICE COPY