21383 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project Identification IPFRMITNO.
BeadingAddress: D E�e'cso w ` 21 383
wneraa one: A p
i5 1-EO'Q CITY OF CUPERTIN0.BUILDING DIVISION
Centmen'ssNNam�e�: n �rQ LIc.No, APPLICATION /PERMITAWL _l
K``b`as n�a Nw-T ('C D CAI 510 BUfLDING-ELECTMCALPLUMBINGMECFIAMCAL CATEGORY CONTROL N
IVArchitect/Engineer. Lie Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERk4TISSUANCE -:t.d ® ❑ ❑
IICENSIa CONTR under provisions
I hereby
cftionmthatlamecensed 3oftheesicamaon9of Cselons9de,and c- APPLIANCESRF.SIDEN7WL JOB DESCRa'nON
ingwhhifon70f10)ofDlvdilan3o(1heBuslnnrsandPm(eulonsCode,and my �r_\q �� C
license Is i fits( and dfect. PANELS 1'C
Llcen RCHI ARCHUP TO 200ANIPSITECTS
Date Contract 'e
ARCHITECPS DECLARATION OVER
AMPS
00 X
pZ (understand my plans shoo be used apubkcrecordw OVER 1000 AMT'S SQ.Ff.FLOOR AREA 5/9Q.FT.
E (1 Licensed Professional SIGNSELECTRICAL
fn f OWNER-BUILDER DECLARATION S['ECIAL CIRCUIT/MLSC
7p, a Ihembyaf .that l am exempt from the Contractor's License Law for the
following reason.(Section 70315,Business and Professions Code:Any city or
Ff' county which require,a permit to construct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
E .a any structure prior to its Issuance, (,.require,the applicant for such permit to
c file a signed statement that he ii licensed pureuant to the provisions of the POWER DEVICES
Contractor',License Law(Clepter9(comemneing with Section 7000)of Divi- gWBdwNG]'DOL ELECTRIC
COQ cion 3 ofthe Business and Pro(esslons Code)miles,he is exempt therefrimand VALUATION
•..tt the basis for the alleged exemption. Any violation of Section 70315 by any �2
�p5 scant for permit the Ileant to a civil 1 of not room than OVILETSSWI7CHESHXTIIREq plea 'L6 a 0(/
fve Rrrrs subjects PP penalty
�y five hundred dollars he pr. NEW RESIDENTIAL ELECIR
O. fin ❑Lasowner,wiH it the work,and my empWyenwith wage as their,ole �'�' SFOW� TYI'ECONSIRIX:TION'
C (Sec.70K Business
and rkandthe structure Code:The
Contractoror or offeredLaw
5 ❑ sale(net apply toano and Pm(egbre Code:The or improves
Lt.herecoe Lad
don net apply Cork ownerofproperty who Wilds orImprovethereon,and
e. who does such workhimsel(orthrough his own employees,provided that such OCG GROUP RES.UNITS
Improvements are not Intended oroffered formic.If,however,the Wilding or TOTAL: I Lt,dO
improvement usuld within oneyearofcompietlon the owner-buaderwlll have
the burden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOODTDNE APN
I,a,owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corolruct the project(Sec.7044,Business and Professors Code:
no Contrsctoh License law does net apply to an owner of property who pLTEt.DRAIN& -WA (EAI
buBb or Improves thereon, and who contracts for such pkojects with a
yy(ractor(,)licensed pursuannothe Contractors License Law. BACK FLOW PROT E FEE SUMMARY
cLI I am exempt under Sec. B &P C for this remon
DRAT FLOOR SANITARY Y_ N_
' Owner Data
WORKMAN COMPENSATION DECLARATION RECEIPT NPER SCI;DOL TAX Y_ N
0
1 hereby affirm that I have a certlBcate of consent to sea-Insure,ora RECEIPT«
cenl0cab of Worken Compevatinn Irnurance ora certified copy thenen((Sec.
3800,lab CJ GAS EA 1 I UTLET PARK FEE Y N
PulCom an GAS EA. -0VE 4(FA)Is RECEIRTN
Y BUILDING DIVISION FEES
Certified copy bhereby furnished. GR DUSrt4L ASTE R PLANCHECKFEE
CerUOed copy is filed with the city Inspection division.
CERTIFICATE OF IXEM"ION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-ft 2 FI. Date RCCCj t#
(Thissection need not be completed If the permit a forone hundred dollars
(SIM)orless.) ENERGY FEE Y N
I mnRythat in the performance of the work forwhicht s permit is Issued, WATER HEATER W/ /E,ECTR _
I shall not employ any person Ina manner so b' to the
workera'Com tion wsof fornl . Dal WATER SYSTEM/TREAn ' PAID
O Applicant AY
Z 0 NO1lUb TO LICAN 1:If,atter king this Certificated Exemption,you NE'WRFSIDCNTIAL PLMB. SQFI. Date RCCeI t#
Fshould become subject to the Workers'Compensation powisioru ofthe Labor TOTAL:
CC N Code,you most forthwith comply with such provkiens orthis permit shall be
> deemed revoked. BUILDING [0 606
dp CONSTRUCTION LENDING AGENCY SEISMIC FEE ..
Humbyaffirmthatthereharoretmctlon lcntlingagenry frrthe perform Tornl: ELECTRIC FEE I ,UO
7 Z ante of the work for which thio permit btssued(Sec.3097,Civ.C.)
V O Lender's Name PLUMBING FEE
IL ~ Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedlfythatl have read thu applicatlonaM datethattheabovelnfomuHon
iscomet.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
). U) relating to building construction,and hereby authorize repreacntatives of this Z city to enter upon the above-meNiorud property for inspection purposes. ALTERORADDTOMECH. Date ReCei I#
V — (We)agree to mve,Indemnify an d keep harmlesa the City of Cupertino P
against kabRltles,I.dgments,.0,and expen,es which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against mid City in cens quenre of the granting of this permit.
AIR HANDLING UNIT(OVER lO,ODOCFM) CONSTRUCTION TAX
Sigiuturp of Applicant/Contractor Date MIAUS'r HOOD(WI DUCT, CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE E-/l
Will the a ppllcant or future building occupant store or ha adle hazardous HEATING UNIT CFO IOgODO BTU) Date RECCI t# TZx
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
I halth and Safety Ccd ion 25532(a)t HEATING UNIT(OVER 10),000 BTU) TOTAL:
❑Yea No
Will the applicant fu re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit to.ideas air contaminant,as deft red by the Bay Area Air
• Quality Management Dist nl BOILER-COMP DFD'OR 100,IXO BTU( PAO®
Yes No PJ
01
4have read the haza o materials requirements under Chapter 6.95 of 90ILFR-COk1P(OVM 100,000 BTU)
the G tifomla Health&SafetyCode,Sections 25505,25533 and 25534.1 NOV07 �r1C1 i�1
understand that if the building docs not currently have a tenant,that it Is my NEW RESIDENTIAL MECFI. SQ.1T. IY Y 1 990
respoesibilty to notify the occupant of the requirements which stbemn
pri�Lssuan_ fa CertiB co(Occu�cy� I City.of Is"�plvpo
acre authToJJrrnned agent D
TOTAL: ISSUED BY:
OFFICE COPY
INAPpRO
a � ACCDRDANCE WH ED
CUPERTINO CITTHE City 0
ODES AND ORDIN F.
NP OATANCES
G� coole —
`� ��
be is sst f plkeptans on
lawful to Mahe on the lob It al mticationsLIS T
oB anY chan3as es and it is un,
the Sam
Without writte er alteration
��o«ble I o�V r J The stimp. 0l tifiSC"J of Cupp3rerti on from
f
------------ . ---- — ProSHAlL N Val f tha o� to p`grtl or Uhce ons
of any City Ordir, ,;R o�SY t RCaprons`ons
ZX(n�
���� tM�'✓!0� ➢12c�ra �, t)l,UV1er
J J
Da-\(['A gas
255= 4 89
(Oh`E f2 cto f ;
M, cC—) Ma5ter(-
-TLrox 2415
ti�J X w 94�h
C. lig# g8435a
p� ' -
Ecun
.
BLDG.Clt'�PECTION OE CUPERiIN�UM
� � YU (TH INS7A LLAT 0 N \5