21611 (2)/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERMIT NO.
Bu lding Address: 21611
n"a G Ae'-wavb.Vle Z CITY OF CUPERTINO-BUILDING DIVISION A A
• Contractor's Nane: Uc.Na:
APPLICATION if PERMIT
BUILDING-ELECTRICALI'LUM8ING-MECIIAMCAL CATEGORY CONTROL p
Architect/Engineer. Lie.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION 10 1�x
I hereby affirm that l am licensed under provisionsof Chapter9(commun APPLIANCESRESIDENTIAL JOB DESCRITION
ingwith Sed on7000)of Division 3ofthe Buslnessand ProfessionsCode,and my
license Is in full force and effect. PANES
License CLk.a
Date
Dale Cant.Ror
ARCHITECTS DECLARATION O AMPS
m0 7 1 understand my ptans shag W used u public records OVER OVER'1000 AMPS SQ.FT.FLOUR AREA 5/SQ.FT.
Uu�O
o Licensed Professional SIGNS ELECTRIGL (
<Ca OWNER-BUILDER DECLARATION
j"n Fn SPECIAL CIItCI11T/M
Ihercby affirm Qallam exempt from the Contractor's License Law fort he
FP.H following reason.(Section 70315,Business and Professions Code:Any city or M N
county which requires a permit to commie Iter,improve,demollsh,or repair
any structure prior to Its Issuance,also requires the applicant for such permit to
yq a W�IO DEVI
fit-V Co a signed statement that he t r9lic(cons encing it the provisions Of the
O
�OrContractors License Law(Chapter 9(commendn with Section Divi- VALUATION
^ slan3ofthe8uslnesantl Profeptssions Code)ortNghebexemptthercfromand SWBdMING ELE C
Q��a//fff
the bash for the alleged exemption. Any violation of Section 7031.5 by any OLP41S-4�kHESFIXTTJREs
applicant for a permit subjects the applicant to a civil penalty of nor more than
a�.y e a k five hundred delta.($SM. NEW AL EL TR
tz 7� ❑I,as owner of the property,or my employees with wages thele so
C SQ •C STOWIS TYPECONSTRUCTION'
� ¢ compensation,will dothe workand the atrodurchnot Intended or offered for
al
$ O se(Sec.7004,Business and Professions Code:The Contractors License law
j$ does not apply to an owner of property who Wilds or Improve thereon,and OCC.GROUP RES UNITS
doessuch work himself or through hisown employees,provided that such
improventenbi arc not Intended oroffemd for sale.If,however,thebullding or TOTAL:
improvement hold withinareyearofeampleio theowner-buflderwlll have
trenofpmvingthat Wdidno[bulld or improve for purpose of sale.). QTY. PLUMBING RMI FEE
as owner of the property,am exdmlvely contracting with littnxd FLOOD ZDNE APN
trade.to coretruct the project(See 7004,8uslnm and Professions Cade: PERMIT ISSUANCE Carl.Ror's Licon
.Law does not apply to an owner d property who
Wilda or Improves thereon,and who contracts for such p0oject+with a ALTER-DRAIN&VENT-WATER(EA)
o9,4.c sE.)ll.esed pu..eittothe Centractor.Littn.Law. FEE SUMMARY
BACK FLOW PROTECT.DEVICE
1_f I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• Owner ECL RECEIPTJI
WORKMANCOMPENSATIONhave
DECLARATION FDCTURFe.,r PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a mrtl0cate of<onseN to.I(-Insure,or a RFCERxf X
mrtlficateaf Workers Comperaztionlnsurance ora mmlfied copy thereof(Sec. GAS EA.SYSTEM-I INC.40UTLETS PARKFEE Y N
3600,Lab CJ RECEIPT p
Policy Y GAS
F.A.SYSTEM-OVER 4 MA)
Com any BUILDING DI VISION FEES
Certified copy ta hereby furnished. GREASE/INDUSIRL WASTE IMI'FltCFPTOR PLANCI-IECIC FEE
❑Certified copy u filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT DBIC RCtt'1 t#
(Thlssedion need not W complRed Bthe permit is for ane hundred dolla.
(EID3)°`less') WATER HEATER W/VENT/ELLCTR ENERGY FEE Y_ N_
I certifythat N the performance of the weak forwhich this permit Is Issued,
1 atoll not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING PAID
Workers'Compensatlonlaws of California. Date
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei t#
Z O NOTICE TO APPLICANT.If, her ma king this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
f0 Code,you mat forthwith comply with such provisions or this permit shall be BUILDING FEE
LU > detroad revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
S Ihercby affirm that there u,a coratmRion lending agency for the perform- ELECTRICFEE
Z ance of the work for which this permit isWord(Sce.3097,Civ.Q TOTAL:
02 Lenders Na re PLUMBING
LL 1– Lenders Add.++ QTY. MECHANICAL PERMIT FEE MECHANI
OW l certlfythatl have read thisappllcation and st+tethat theabove Information
(U Is correct l agnmto complywlth all city and county ordinances.nd+=I.ws PERMIT ISSUANCE FEES PAID: {$��
N orating to Wildingconswction,and hcrcbyauthorize representatives o(this meal O�`'`3ZF/
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. D—igt'w Receipt#
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT 1T010,000 CFM) -
agalnstlhbNfir Iudgme cossfa dexpen. whlchmaylnanywayacenue $UBT.XD—I"
old C1 s tt0f the I oft spemml[.
AIR ITANDLING UNIT(OVER 10,000CFM) Cet.41Z-Zks ONSTR ON TAX
�graturc ppllcaDate IXHAUSTHOOD(W/DUCIT CONST � TAX PAID:
A RDOUS MATER CLOSURE
Will the applica of or future building occupant store or ha od le hazardous HEATING UNIT(TO 100,000 BTU) r� D tea R ei t#
material as deo ned by the Cupertino Municipal Codc,Chapter 9.1 2,and the
I ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ye LJ No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 0,re'4�l'{ ATE
which
D
h et hem s contaminants.,defined by the Bay Area Air
�d
QualityManagement
ai[,riot?cot raBOILER-COMP(3FB'OR 100,000 BTU)
4 Ye No
have read the h.a ous materials.qulmments under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Califemiz l leaith&Safety Code,Sections 25505,2x533 and 2:534.1
undeodand that if the building does not currently have+tenant,that it is my NEW RESIDENTIAL MECH. SQ.ET (T7.F dyY7ryp
responsibility to edify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
JV +r
TOTAL:
OFFICE COPY