21620APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project IdeatiflationPERMIT
Building Addreu: -
NO.
21620
• �ydZOl1� me
CITY OF CUPERTNO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECIRICALPLUMRINGMECHAMCAL
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1
COnha"�•�•^° _
CATEGORY
CONTROL e
Art�LLL�tt/Fs rcrr. s LIB Na
Q ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Address
-si IQ�
La ZY
PFRMETISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby drum that t am licensed under provWeea of Chapter 9(mmmmc
Ingwllh5eeion 7f)(CM Dlvblon 3 orthe Businsasand l'mfessa.Code,and ney,
11¢ose is In ruB((..��e and dfe ,L�j���
APPLIANCES -RESIDENTIAL
N
PANHS
Lkxrsc CWr _L�Lk.s 4SOC 1 /
F OW .
Date Contractor
UP TO 2DOAHM'
AMPS
ARCHEIECI 5 DECLARATION
I urderst.ed my phrushag be used as publicrecords
OVERI000AMPS
9Q. Fr. FLOOR AREA
S/SQ. FT,
SIGNS ELECTRICAL
LI¢raed professional
OWNER -BUILDER DECLARATION
Thereby al . that Iamexemptfromthe Carrcnctsio License law for the
wing which qufreermmed, to BYalnsand ,irrpm,ns Code: Mycity or
county
muvtywhich requlrs a pemet to mmwe, alter, Impmvq derreLLah,or rtpilr
SPECIALCIRCUITRAIS
63
TEMP. METER OR POLE INST. -
any structure prior to its issuance. 1. req.]ee the appllant rorauch pemdt to
Bb a signed niter ent tlut he is B¢vsed pursuant to the proosbm of the
Contratlols License Law (Chapter9(mmmencing whh Section 700 or Divi-
sion3 of the Buadn. and PmrmbroCeds) or that M b exempt thardromand
POWER DEVICES
SY/B.1h9NG POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 7(131.5 by any
appllont for a permit subjects the appllcavt to a dol penalty of not mm than
Ileac ndrcddollars rathe 00).
aowrer ofthap empbyen wkhwaguutheir
Ol7fIEISSY.gICHSFIX[ UR6
I
NEWRES1DFMIALELEcTB '�'�'
S TWECONSTRLCfION
oVer191
rsale for
mrripcnutbn, will doRa,tru the w¢k,aeaskrea
work,. dt a mtlMeMed or offered
7044 Prar.bro Code:rhe Contneors
an ode: Th Law
L Easb(Sec
IN
to owand
the.
dos not apply toN owrerd property who beideor lmprovn thareoR and��who does such work himself¢ through his own employes, provided that eachImprovements
am rout intended oroffered for sale. IL however, thebullding or
theowner-bufduw ihavet
TOTAL:improvementbwWwithinonsyearofcompletb
gNA�
e rden al proving thatha did not Wild or bnprove fee wm� ofsaleJ.
' L as owner of the property,am exchatvely mntraciing whh B —
contractors to constructthe pm)ect(9ec. 7044 Bualnmand Prar.bu Code:
QTY. PLUMBING PERMIT FEE
ODID
1
�t
PFRMH ISSUANCE
The Contactor'. License Law don not apply to an owner ar property who
buddy or Impremnra
noses thereon, and who tces for such p(o(eea with
oplf+eods)licnsed pursuant to the Conuadoes License Law.
LJ I am exempt under Sec B k P C for this reninOUTSI
ALM -DRAIN k VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DE FEES
DRAINS- FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y_ N_
RE T PT
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affIerk that L have o ¢r 6rateoranc of consent to op thereoflausurs, ee
Workers Camprnsatlonlmuran¢eea¢rtifled copy thereof (See.
3800, Lab C)
38W,certifilte ash
SCHOOL TAX Y_ N_
RCiFdPT a
GAS EA. SYSTEM -I WG4OU-D.EIS
PARXFFE Y N
GAS EA.SYSI' -OVER4(EA)
Copol
�mp+nv cr✓.r CC.t GTL
BUILDING DIVISION ISION FEES
DING DIV
I 1 C<rtNN copy 1• hereby furnished
Ned copy b filed with the city inspection divlelun.
GREASE/WDUSRI. WASTE INTERCEPTOR
PLANCHECKFEE
GREA'SE'IRAT,
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thisection need oat be completed Btha permB b forcerforcerhundred dallvs
PAID
Date Remi tit .71 SO
SEWER-SANITARYSIORMEA =
(S1 W))er lmJ
I¢rtifly thxbthe pedorman¢of the weak for which WspemdtbfsaN,
I -hail not employ any person in any manner n as to become subject to the
Workcn' Compenution laws or California. Date
WATER HEATER W/VENT/EIECTR
ENERGYFEE Y N
PAID
WAT1R SYST MrERFATl
Applicant
Date Recej tit
NEWRESDENTIAL Pi.MB. 9QF1..
amid b TO ne, sub CAM:IL anter ms' Conthio Certificate is Ezcmmpptt a Lyou
the Workers' Compematlonprovbbnsorthe all be
Code,y enmat forthwith
dee�ou�lked. lth comply with eaN provbbra or this pemJt shill ha
CONSTRUCTION LENDING AGENCY
TOTAL'
BUILDING pay�js
EISMIC FEE s7t9
Iherebyalflrm that them in ammtrunlm lending agency for the perhere,
anof the work for which thio b bued(See 3097, CW. C.)
TOTAL.
ELECTRIC FEE
Lender's Name h
Lender. Added �'�
1 ¢nlfythat I have read thb•pplhtbnard Matethattha above Inforrnstlm
bmrmcl.IdgreetocomplywlthaRcityand muntyordbanmaed gate [am
QTY. MECHANICAL PERMIT FEE
WING
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
PERMIT E39UANCE
relating to building mretructlon, and hereby authorise mprmntabvs of this
city to enter upon the aboverrentloeed property for Inspection purposes.
(We) agree to aster, Indemnifyre
an d keep had. the City d Cu peelre
against liabilities, judgments, oasts and expenses which may, N any way seeue
against said City he mnsequ eoee of the fins Mbig of this pemet
T
� 1I ),I n\
ALTERORADDTOMECH
AIR HA LADLING UNIT(TO 10,000 CFM)
Date Reeel tat
SUBTOTAL:
AIR HANDLING UNIT(ovER to, CFM)
CONSTRUCTION TAX
1--
� cmr
9lgnsture of App antARDOUS MA
FIA]A RDOUS VIALSDISCIAShhand
FXFIAl15T HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMT(TO 100,000 BISn -
building orham9.hazardous
Will onneria the applicant by the up Cupertino
goaipal Code,
Cuon255MunicipalCode,chapter 9.17, and the
Date Recei tM
rrFATIIJG UMTroVFR 1oo,ODD BTIn -
lm�_
TOTAL:
H1althi.s SccIy .dthe
IieillhaM sdetycndrenu–S,ealon 25531a>?
No
W Ys fu
Ol thc.ppllrenta tort bullding mvpantux equlpmenteedevkcs
which eMt lunr airtents u defircd by the Bay Ams Ab
VENTILATION FAN (SWGLE RESID)
]$ DATE
BOIfER-0DMP OHP OR If10,IXD BTU)
Quality Navnesed geeM District?
Ys F� No
have read the hav�ws rrweriab requirenann underChapter 6.95 of
F E 9 141991
BOILER COMP (OVER 100,000 err))
the California I lalth 6 Safety Coda Sections 8505, 75533 and 75534. 1
®EN
NEWRDTIALME(}L SQFT.
undentard that If the building does not currently hab
ve. tenant, that it ey
responsibility to ncx Lfy the occupant of the rest imnrNe which rmnp be ret
gy
yltl if�1111n rn�
�.r
prior tossua
Ince of a Certificate of O�mrpancy.
�
_ r "�,oIJ.L,n \ I'LL
�_ •
ISSUED BY..�/CY_
Owneree.uth� .gem
I Date
TOTAL:
OFFICE COPY