21385 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PERMIT NO.
"-`°g0 d CT 21385_
ante, one: A A
rocs , ,ev CITY OF CUPERTINOLBUILDING DIVISION
mdnra Name: ie.No: APPLICATION /PERMIT l
• Ai4.aa.Q �E2 BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL
A (teat/Engineer. Lk.No.
- "' ° ' " ^"' RMI"� et ="'"` ti, ' BUILDINC,PERMIT INFO -
q
QTY - ,ELECTRIC PERMIT a' a11 s,, FEE - . .. -
leFRhITI55U0.NCE � ❑ ❑ ❑
LICENSED CONTR under provisions
TION
I hereby onmthat Divisiam ensedhe Busi ossand of Cssions9(mmmmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
inensei in ion7000)onDieffect ofthe BustnessandProfessionsCadeend my
license le in full(oIm and d(ett. PANELS � 1�_..j
Licen Class�'�Lic N
Data Cordnmr moi/ 701.1000 AMPS
ARCHITECTS D C ubhc..ON
reO Zp ]understand my phru shagW used upubBcrtmeds OVER 1000 AMT'S SQ.FI.FLOOR AREA f/SQ.F7.
� (/ Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECNLCItCUIT/MIST
F. 7� IherebyafOrm that I amexemptfromthe Contractors Llcewe Lawforthe
following reason.(Section 70115,Business and Proleastans Code:My city or
to TFbIIs.METER ORPOLE INST.
oatntywhkh requires Mtbmminessaemot ld Profpmve. Code:Any
ir
or
anysuuciure prior b it issuance,also requires forsueh permit to POWER DEVICES
:
:,,U file a signed statement that he is licensed pursuant to the provisions of the
!3c'1n Conmedoes Lkeme LAW(Chapter9(mmmrcncing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
don3 ofthe Businneand Pro(eseumCode)mthat he is exempt herefromam! VALUATION
<s the Weis for the alleged exemption. My violation of Section 70115 by any OUTLETSSWITCHESFO(TURES +.(t O t5 add
Pp0¢nt fore permit subject the applicant toe civil penalty of nu mare than
- five undred dollars(SS00). NEW RESIDENTIAL ELECM SOFf. STORIES TYPECONSI'RUCTION
..�, �I,as owner of the property,or my employs.with wages m their sole
mmperwt(on,willdothework andthestrutture h nmintended or offered for
D sale bee 7064,Business and Profeaioru Cade:The Contractors Lt..Law
don not appy to an owner of property who halide or improve thereoe.and
^ ^ who docs surhwork himself orthrough his own employees,provided that such .GROUP RES UMTS
Improvements sre not intended oroffered for sat.ILhowever,thebulldingor TOTAL:
hnpmvementhsoldMhinom)marofcompldby.theowner-bulWerwRlhave a, ,�_r_., „ys
t rdm of proving that he did not build or improve for purpose of We.). 'Qj'y, :4;x,t`y,:aPLUA'MBINC-PERMI'l�wi.,`tb? _ E DZONE APN
LJ L as owner of the property,am exclusively mounding with licensed PERMIT ISSUANCE
mntracion
, License
ss utmct the project(Bee 7056,Bwteand Professions Code:
The Contractors License law does not appy ta an owner M property who ALTER-DRAIN&VENT-WATER IFN )
builds or Improves hereon,and who mntnm such for paojem with a - w
mraqactor(s) pursuant to the Contractors License Law. ,
LJ I am exempt under Sec B&P C for this reason BACK FLAW PROTECT.DEVICEW FEES
OwnerDate DRAINS FLOOR,RODE,AREA,ODND. SANITARY Y N
❑
WORKMAN COMPENSATION DECLARATION RECEI7'M I hereby aRbm ce
that I have a mHw¢
Oeste of consent to self-b ,or a sPER TRAP SCHOOL TAX Y N
RECEIPT N
mrt0imeo(Workers'Compennlionlmuran¢¢a¢rtlfled copy thereof(sec. GAS EA.SYSTEM-I INC{OUTLETS PARKFM Y N
3800,Lab CJ ,/yamFz
PoligN t___JpW 3 GAS EA.SYSTEM-OVER 4(FA7 IN
Cam any / BUILDING RECE
DIVISION FEES
�Cedlfied pys hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Cedilied mpy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(TMssedbnneed notbecompleted lithe permit hforom hundred dollars SEVER.&ANITMY-STORM EA.20BFT' Date Recei t#
($100cerdfyt.) m
I rdlytWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
hat the performance, work forwpermitch this permit la issued,
I shall not employ any person b any runner m u to become subject to the WATER SYSTEM/TREATING PAID
Workere Compensation laws of California.Date
Ct Applicant Date Recei t#
Z NEW RESIDENTIAL PLMB. SQFT.
Z O NOIICETDAPPLICt to
.,kerstYdnglhis erastion Certificate of Exemption,you
afimld become subjett to the Work<n'Comptwtlm provisions of the Labor TOTAL:
XN Code,you manse forthwith comply With such provisions orthh permit shall be BUILDING FEE 10
W j deemed revoked.
CL c CONSTRUCTION ucroniGAGENCY SEISMIELECTRIC
t
]hereby aorkfahattharehaermiixissud(Sec. 0W,Civ.C.) pedorm- TOTAL: ELECTRIC FEE
7 Z arm of the work farwhich this permit hiesued(Sec.3097,Civ.C.)
C, O Laml,,s Name �✓sN-NA r,d:,'� a. ,. ... PLUMBING FEE
F Lender's Addm¢s QTY. =MECHANICAL:PERMIT.; p ;, FEE';`
O W I ¢dlythet I have read thhappB¢IonaM statethatthe above lnfommtine MECHANICAL FEE
fL barred.I agreetoccmplywlthallcityand muntymdlnancesand statelaws PERMIT ISSUANCE FEES PAID:
r N relatingtobulldingmmtrocticn,and hereby authorize repreentativesofthts
I— Z cayb enterupon the above-mentio¢d property for Inspection purposes. ALTERORADDTOMECH. Dale Recei t#
(We)agree to rave,indemnify an d knep harmless the City of Cupertino P
V agaWtliabWtles,jadgrrent,costaand expenses which maysnanywayaccrue AIR HANDLING UNIT(PO 10,000 CFM) SUBTOTAL-
;ga7 dC�Ity ,pn. `' of I' e granting of this permit
\�174_�n/Jy fJJe.(—t/✓wc�ssOl AIR HANDLING IIMT(OVER IO,000CFM) CONSTRUCTION TAX
siSrtureof Applicant/Conten Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
Will the applf¢nt¢future building occupant store or handle hazardous HEATING UNIT GOI00,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the 0
Health and Safety Code Section 25532(a)7 BEATING UNIT(OVER 100,000 BTU) TOTAL: c
MYea T,No
Will he appll¢nt or building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air mntambunt as defined by the Bay Area Ab }�
Quality Management Dlstridl BOILER-COMP DIV OR I00,DM BTU) PAID
4Y. ❑❑No
1bava read he hazartlaa,rmbriah requirementandm Ghaprm 6.95 of BOILER-COMP(OVER100,0170 BTU) (' ''--77 11
the California Health&Safety Code,Sections 25505,25533 and 75534.1 IJGV I/ I IyS LI
understa na that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT
responsibility to notify the occupant of the requirements which must be out
prior to issuance of a Certificate of Occupancy. City of Ointe.hrtn
Owner or authcrired agent Date TOTAL: ISSUEDBY: V
OFFICE COPY