21621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulldl Pmea Weriflatlon Co a PERMIT NO.
Building
Address, -t V-�oot� v,'LL- �o U-v-T P i 6a N 3 8 C LT, 21621 ,
< . me.
Q CyP,or,)p CITY OF CUPERTINO-BUILDING DIVISION
contaaor'a tJame: ���. C APPLICATION I PERMIT
1 BURAINC-E].ECfR PLUMBING-MECHANICAL CATEGORY COVfROLY
Anchkcct/Englmen Ec No,.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address A
LICENSED that ED CONTRACTOR5 DF.CLA RATION
I hereby n7OslutfunI =3ofunderprovblmsof mf]a s9de,r Rite BDESCRIPTiDN
Ingwllh Scalon7000)of DlWsiml3otthe BuNnmmdProlesdons Code,and ice. �/+y� 10
I leanseClam �7 In full�e kand disc[. P te/ O M P T S}�o wL,
lL `T�Ji/
Date Coma=,
ARCHITECTS DECLARATION 201-1
�'Z I understand! na my plarhnli be used u A
public records. OVF12 SQ.FT.FLODR AREA
$/SQ.FT.
Licensed Professional SIGNS crrosCan. �)ZProfessional
�<D OWNER-BUILDER DECLARATION 'saLCIIRCU['T/MLSC
z � 1hembyaffi mtlu ,.0 emptfmmthe Contractorb Lkeve aw lm he ry1�
ORr following mawn.(Sealon 7015,Business and Profembv Code:Any city or TFMIa.METPR ORIOLE WST.
PMV cvuntywhichrequMaper tocorutru"ter,lmpr ,dertnlbh,ormpalr
gy,,� anystruaurc prlorm lh bsuavu,elm rtquBesthe appBcentfmwdi permit to POWER DEVILS
C',6 Rle a signed statement that he b licensed pursuant to the provbus luof the
;u, Contrabor:Recess law(Chapter 9(commencing with Sec lon 7000)of Divi-
OS don3ofthe Bualneae and PtofemlonaCde)orthat hebexempt thercfromad POOL OL ELECTRIC VALUATION I
<i the basis for the alleged exemption. Any dobtlon of Seab01177'E75S1Y17C11F_SFDCTfJRFS
n 7(315 by any
P +PPBanttoraper tsu *j th,.pplo tt.aa 1pe.Ry&.a.n th.. a0/ S/
E rave hundred dollars CIS".
�n ❑I,as own,of the property,or my employees with wages as t6etr sole NEW RESIDENTIAL E.ECTR SQFT. STORIES TYPE CONSTRUCTION
compensation,wBl dothe wm4,and the structure b not Intended or offend for
❑❑ n aak(Sec 70K Bushes and Profemlov Code:The Contractors License Law
�}s@ does retapply to ae owner of property who build.or improves thereon and OCC.GROUP RFS UNITS
EE.• who dosssechawrkhlmseU orthwgh hlaownemployees,provided that wch
bnprovemlente arc rut Intended oroffe,ed fm ule It,however,thebulle ing w TOTAL,-
improvement
OTALImprovement b sold within oneyearceompletloM1 the owner-bu Alder will have
If)9.¢urdenofpmv1ngth9tedm not build orlmprove fee purpose ofub.). Q7y, PLUMBING PERMITFEE pLOpp ypryp APN -
L_j I,a.—Cir of the property,+m excWahrely rmNwk
drang h licensedpp(MIT ISSUANCEcontractor.to mrutma the project(Sec 70K Businessand Profemloru Code:
The Cctragi ols L4vrue Law does not apply to an owner of property who ALTERDRAW&VENT-WATER(EV
Wild. or Improve thesmn,and win contracts for such ptoj-m ALTER
DRAIN• FEE SUMMARY
ogDllaetpursuantm
.)Burned pursuant to the Contna :License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for Nh reason
Owner IDate
DRAINS FIDOA A,ROOF,AREGOND. SANITARY Y_ N_
REOEPT
WORIQIAN COMPENSATION OECLAMTION p ee PER TRAP SG'IDOL TAX Y_ N_
❑I hereby af(Im,that 1 have•certificate of consent to sell-Insure,m a RECEIPT Y
380(LI C-Worken'Cmnperertlonlvurmce ma certl(led copy thertofCec GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
polis Lab G)
RECFII'T�
Co CAS FA.SYSTEM-0VFR I(FA)
Comm env was�t0 { BUILDING DIVISION FECS
I ICertNed copy 1.herebyediftumbhed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCI�]ECK FEE
Certified copy b filed with the mY Iv)anaWn dfvldm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA-'�TRAP PAID
COMPENSATION INSURANCE SEWiE,&ANITARYMRM F 200FT Date Remi tN 9
(Thin section need not be c«npleted litho permit it forces hundred dollen
(8100)m1nththat
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
]certify y at In theperfperformanceanof The work for which this pemdt is issued,
I shall not employ any pence,In any manner an as to become subject to the WATER SYSTEM/TRFATIt.G
Wakan'Compevatfon L,vs otGWomla.Date PAID
PP NEW RESIDENTIAL PLMB. 9Q}T.
A lion[
Z0 NOTICEco esub),ttothe orifter makingthbCeion,proof Exemwbn,you Dale TA t>Y
should become subject m the Workers'Compemecon pmvL+lov of the L.bor TOTAL:
W~ N Code,you mart fmthwlth mnp"Lli suds provbloru orthb perdu shall be_ BUILDING FEE
j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction larding agency for the perform ELECTRIC FEE
Z enteoftheworktorwhkhthb pe tin issued(5c,3097,Civ.G) TOTAL:
00 Lender's N.me PLUMBING FEE
U. H Iender.Addrem Tt` QTY. MECHANICAL PERMIT FEE
O wIomffyUbial loswreadthbappllatlonad ratetnattne,m.-e wnmnacmn MECHANICAL FEE
bmmm.IagreetocanplywhhaUdryaMcountyoMl ano:sendeatelam PERMIT ISSUANCE FEES PAI D:
} N relating to building covtrualmy ad hereby authwtre reprcxntadves of thin
Z City to enter upon the above-mentioned property for lropMlon puses. w ALTER OR ADD TO MECH. Dale RLYeI [71
_ (We)agree to save,Idm
erdly an d keep harmless the City ofrpopertl
agatrut Wbititia,Judgments,"a and expenses which may In any way acerue AIR FANDLI NG UNIT(TO loOuOanM) SUBTOTAL• _
ega Wt said City In conaequence,of the granting of this pemnIt. AIRHANDLLNG UMT(OVER IBUB0CEI) CONSTRUCTION TAX
slgnamrc� pppp1 and//Cont,or h��iIpaic D(HAMHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMAVERIALS DISCLO URE
A WBltheappBantrofuturebuBdingueaupantatoreorhadk havrdous EIFATING UNIT LTO 100,"BTU)
mbirrbl an defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RixeI tIl
Elexhh ant Safety Code Seaton 25532(.)7 EffATING UNIT(OVER 100,000 HTJ) TOTAL
❑Yes No
WBl theapplhntm tort building omupant use equipment or it v VENTILATION FAN(SINGLE RESID) IS4LYWWATE.
whkh enut hanrdous air contamdnants u deBrcd by the Bay Area Air e'w�
Iky Management Dl tlet7 BOILER-NMP OHPOR 100,000 BTU)Y's FEB �I 'I 'I
slave Aad theh No
mous matenias rcquircmenb un der Chapter6.95of BOrLZR-COMP(OVER IM."BIT!) EB 1 4 1991
the GBfomla Heahh&Safety Code,Sealov 2S5 .21533 and 255X. I
udmtad tlutif the building don riot currency have tenant,that ltbmy NEWRINDFNUALMECH. SQFf
mpovibBly to notify the occupant c(the requirements whkh mist be met
prier to issuance of a C ,`uBa-tee of Oaupacey.
Owner mss auth agent Da ISSUEDBY—TF PiUj
TOTAL
OFFICE COPY