21459 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Project IdenJlk.ti n PERMIT NO.
Rulblg`Ad'drt�:1 X10(6-7 � F�eA��u� mR; 21459
77 a�/ � 1� 0-0 t Zs-?' axt CITY OF CUPERTINO-BUILDING DIVISION � a�
contrad^r'sN—Siz' IJc Na APPLICATION / PERMIT W
BUILDINGELECTRICALPLUMBINGMECHANICAL Gl➢GORY If
Le.Na CONTROL
' Arthlte¢/Engineer:
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
CONTRACTOR'SLICENSED DECL
ARATION PFRMITLSSUANCE ' ❑ �q
1:1Ihaffront that lamv undermvlChaper9(ox � APPLIANC6RE4DFNI7ALpg DESCN
IngwthSmb.7000)o/Dh4.3ofLh,BUMu,.dPolmuCade.dmy
❑
I
Ilmroe W In/uR form and died. PANELS n tCJ-
LM:we Clam LIc1 '
Date Commetar UP IQ 209AMPSel
ARCHITECTS DECLARATION 1-1000 AMPS ref
WW2 Iurderamnd my pha s)ull be u.<d upubllcr vice OVER1000AMP5 • I I EQ.Fr.FLOOR AREA S/SQ.FT.
Cy,OE Llavd Pmfembn,l SIGNSELECTRICAL p..
6 N OWNER-BUILDER DECLARATION a grE0AI:CtRC111T/A95r
,F 7, Iherebyaffiren that l un exempt from the Cmdnnor'a License Law for the -
62qQ following rtaamb.(Berton 7Q415,Buslnm and Profmbro Code My tlty or
Ip"p� =mywhich requiresa perm!ltomvtructaler,Impmve,demoWh,orrepalr '- TII''�'M ORPOLEINST.
qqqq`�5� anyatru—m Irbrtolb baa.,also requbntheappBmnt forsuch permit to ` \POWERD
!0e a signed mtement that he h Boomed pumeaWbro
nt to the proof the `N s p a
r Contradees Lkeme Law!Chapter9(mmmenMg with Section 70=of DM- SWLIAIING Pl70I.'EIFLTRI.
lan3of Ne BuaWe dPmfmWmCnde)ortlathebeumpttherdmmand VALUATION
�bub for the alleged exemption. My Anixa n of Se tion 7001' by any .A IIIt 0
applicant foorrapprmit dsthesppllunttoativll penaltydnd e'lhao 70ITILE7SSWCTGI-IES
fi
� SSOV.
�n ��yyQQ��l!yy,,++udd owelr of th<property,or my employees with wages u t so1L 1 NEW RAESmENT1ALELFGTR SQ.FT. SIDRIES
TYPE CONSTRUCTION
C �pev tim,w dothework andthetmmmbratit or offs tar A\�
$ O W(S( 70K Buskam and Profemloro Cade:The Contradora Llceroe
dm notapply too owner of property who Wilds or improv,thereegfeed /TOCC.GROUT' RES.UNITS
whod^nuchworkhlmsetf mthrough hbownemploym,provided that:uch
Improvements art not Intended oroffered for sale.If,however,the building or d TOTAL:
improvement Is"wlthirionele,rofcompldl Ntheownn-buRderwill have
t"mien of pnwing that he did not Wild or lmprwe for purpose ofsae,.). '4LUMBING PERMIT FEE
UL u owner of the property,am exchahroly contractlog with Ikensed FLOOD7DNE APN
eentrsetma to..et the pmfect(See.7D44,Buslnm and Prefemba Cade: PERMIT L$UANCE
The Contrador's Llcerue Law dm not apply to an owner of property who -fl
Wnll'u or Impr therms, ad who comm for such p�o)ccts with a ALTER-DRAIN 4 VENT-WATER(EM
cgaLVdaa)II¢nsed pumant to the Contrador's License Law. ' BACK FLOW PROTEC'[.DEVICE FEE SUMMARY
U I am exempt under Sec B k P C for this reason
Owner DRAINS-FLOOR ROOF,ARFA,COND. SANITARY Y_ N_
Dale RECEIPT a
❑
WORKMANPJSATION DECLARATION HfTURF_S PER TRAP SCHOOL TAX Y_ N_1 hereby,(firm I have
that havee.•mstlflote of..of to xN-Iwrt,m s
Mrtiflaof Worken'Comperuatlm IMnralrce ce a mNfled cxrpythenof(Sec.
RECEIPT
3800,fabb CJ GAS EA.Sri-Ihlf-t WC./OUTLEIS PARK FEE Y_ N_
1 bya GAS EA.SYSTEM-0VER4(EA) RECEIPT/
Cam ^Y BUILDING DIVISION HEB
Cedlfied ropy Is herebyth the d. GREASE/INDUSTRL WASTE INTERCkPIDR PLANCHECK FEE
Cenlfid ropy Ned with the city,Wpecrion divisor.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCEg}yER-SAM'IARY-STORM EA�r Date Receipt#
(This ambn need not be completed lithe perndt b for oro hundred do0ars
(5100)eeless.) WATER HEATER W/VPNT/ELECIR ENERGY FEE Y_ N
I unify that In the performanm of the work for which this p mrdt Is Loved.
I shall not employ any person In any runner m se,to become ubyet to the WATER SYSTEM/TREATING Workus'Compensation Iowa of Callforrda.Date PAID
O = NOTICApplicaE
NEW RESIDENTIAL PLMB. SQFT. Date Revel t#
_Z O ND]10E TO APPLICAM:Rafter nuking this Certificate of Exemption,you
should become ub)a to the Workeri Compemudt provbloro ofthe Labor TOTAL:
F"'fn Code,you must fort hwlth comply with such provblora or this permit shall be
`J deemed rtwkd. WILDING FEE
WO CONSTRUCTION LENDING AGENCY ISMIC FEE
a Ihrmby,Ifirmthat then b,coratrudlon kndingagency!^rthepedorm TOTAL: ELECTRIC FEE
7 Z arm of Ne work(or whkhthb permitbbusd(Sec.307J,CW.CJ
() O Lender'.Name PLUMBING FEE
LL I— lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FCE
O W lmn Oy LhatlhawmadthbapptraO nandeatethattheabovclnfonrotimr -
a bcormd.lags to comply whha0 tltyand county ordbuneen and late lawn PERMIT ISSUANCE FEF;PAID:
relating to binding mrutsudlon,and hereby authorire mpomsematNn of this Z dry to enter upon the above-mentbrcd property for Impedbn purposea. ALTER OR ADDTO MECH. Date Revel tit
— (We)agree to neve,Indemrdfy an d keep harmlem the City of Cupertino
S.J.labWtles,ksdgmeds,cols and expense which may to aryway.cwe AIR HANDLING UNIT GO 10,W0 CFM) SUBTOTAL•
agabat said City N consequeroe of the grating a(this Permit.
IA t A��6/7 AR uNDUNc UNITrovFR lo,000cEM) CONSTRUCTION TAX
t.ofA am/cantradm „i�l4�at'�7-- E usr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will
the appBat orfuhim building orrupant store or handle hazardous HEATING UNIT(TO 1D,f100 Bft1) Date Revel Ip
material a defined by the Cupenlw Mudtlpal Code,Chapter 9.17,and the
I kalth and Safety Cade Section 75537(S)r
F1 Ye HEATING UNIT(OVER 100,000 BITJ) TOTAL:
No
Will the appliat or turebutIdingoceupant use equipment ordev VENTILATION FAN(SINGLE RESID) I$ ATE
whkh smith rduusdr eent.ndnumsas defined by the Bay Arta Air
Quality klarogemed lYatro
yes
C3HPOR 10,000 BTTI) y
lot 1-` 19exo
❑ ❑No Y
hove read the havNous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTT!)
the California Health h SafetyCode,Smloro Z505,25533 and 25534. I
urderland that If the building don not eurrenlly havoc tenant,that it is my NEW RESIDENTIAL MEIN. SQ.7. �ylss sa{
responsibility to notify the ocapint of the requirement.which must be met YB. Yj
prkx to bnuame of s CenlOate of Occvparcy.
Ownrror uthonad agent Date TOTAL ISSUED
OFFICE COPY