20210 (2)(ie
00
f9
a
OR-
F
°offHui
ai
pCOOOY' � O
T.
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT -PEN ONLY
Building Project
Bolding Add.: ��t�,�<�)i1 �,,
'];�;j,�
PERMIT NO.
- 20210
m6�e•;6++�r1�f,/
wnera cense:
E'EAl /%10"A GVOU
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINC-ELECTRICAT PLUMBING-h1ECHAMCAL
�i 111
c°"trado aNamn: ' Lm.N°:
CATEGORY
CONTROL It
Architect/Engineem Llc. No:
N
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
/, /+
Acid— /.h v6 f%jr/,1 t .rCli�'fri a - J• .�:
PERMITISSUANCE (M
❑
LICENSED CONTRACTOR'S DECLARATION
I herebydn7OODafDimeimsefth.BupmumdPrlChapter9(mmmne
Ingwgh i.f.di7(XIO)of Ddelon3ofthe BuelnessandProfnelonaCade,and my
Ranee la In fug fo .ndctfett. ,y9/v Hb e1
LIcen�Contr
Tete Contraor�?iL(�
ARCHITECTS DECLARATION
I understand my plans shag be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION -
Thereby afRmnthat l am exempt fmmthe Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit M construct, alter, Improve, demolish, or repair
any structure prior to its bauame, also requires the app ,.orforsuchpermitto
III... igned statement that he Is licensed pursuant to the provisions of the
Contractor's License Gw(Chapter 9(mmnpncing with gectbn 7000)o(Olvl-
slon3 olthe Busnemand Professions CWd )mrthatheI exempttherefmmand
the basis for the alleged exemption. Any violation of SeciWn 70315 by any.m
applicant fora permit subjectsthe applicant to a civil peaky dna more than
five hundred dollars (SM.
[:]I, as owner of the property, or my employees with wages as their sok
cumpenaation,wilidothe work and thestrudure it not Intended or offered for
.In (Sec. 7064, Business and Pmlessions Code: The Cmdracte. License IA.
does not apply to an owner of property who Wilds or Improves thereom and
who doessuchworkhlmeelforthrough hlsemnemployees, provided thatsuch
Improvements are not Intended proffered forsale. If, hawevegthebullding or
Improvementbsoldwlthle oneyearofcompietloNtheowner-W Ilderwill have
tFgLIturden of proving that he did not build or Improve for purpose ofak.).
LJ L as owner of the property, am exchuively contracting with licensed
contractors to construct the project (Sec. 7034, Business and Professions Code:
The Contmdor's License Lew don no apply to an owner of property who
or Improves thereon, and who contracts, fee such p(ujed, with a TFEE
�ado,(,) licensed pursuant to the Conmedoe. License Law.
J 1 am exempt under See - B h_ P C for this reason
APPLIANCESAESIDENML
JOB DESCRB'170N
/ 0uv _
v` �U//�;'y-'JY
,
PANELS .�:''
201- 000 AMT'S It
OVER 1000 AMPS
SQ. FT. FLOOR AREA
'
$/SQ. FT.
SIGNS E C L
SPECIAL CIR
'IFMCM PO I
C
[ppL ELECTRIC
i
VALUATIOto
C.J"
'
Ng D EC7R �'FT'
STORI[5
TYPE CONSTRUCTION
-
TOTAL: ILat�-
QTY. PLUMBING PERMIT FEE
OCC .GROUP
RES. UNITS
FLOOD ZONE
APN
PERMIT ISSUANCE
ALTER -DRAIN &VENT • WATER (WWads
SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS-RDOKROOF, AREA, CONE.
p0(TVRES PER TRAP
SANITARY Y_ N_ -
RFCEER N
Owner Date
WORKMAN COMPENSATION DECLARATION
C31 hereby M. that I heve'e certificate of consent to self -Insure, or a
certificate of WorkeWComperuYlon Insurance ora andfied copythereof(Sec.
3800, Lab C.)
licy p
SCHOOLTAX Y_ N_
RECEIPT N
GAS EA. SYSIR.{-1 WC.60UTLEIS
PARK FEE Y N
RECEN
GAS EA. SYSTEM -OVER 4 (FA)
Comp
Company -
BUILDING DIVISION FEES
DING DI
Red copy Is hereby furnished.
CertVled copy is filed 'with the city Inspection division.
CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
TIM. dlonneedndbecomplmedlftheperMtbtoromhundmddollare
(5100
1, le ')
I artllyt
hlhb permjt is lacued, I.hallnote 4. �11p any ma so sa t totheWorken'C0waCLGlI(o . D t
pplletnt/ ��llii1
GRFASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date fiscal t#
O
GREASETRAP
SEWER-SANRARY-STURM EA 2(IOFT
WATER HEATERW/VENT/pfECTR
ENERGY FEE Y N
PAID
Date RCCei tN
WATQ{SYSTFM/TREAnNG
NEW RF9DENTIAL PIMR'—TQ'FT'
feWAco.fthnwmkf�01Wnaofthewmkforw
rmalddg Certificate of emprcr, ou
!,.cele b •i yshould bemeWo n'Compensatbn provbbns o(the LaborTOTAL:Code you nvcomply with such provisions orthbpemdtshallbe
deemed revo
UCTION LENDING AGENCY
Iherebyare leaconstrudlon lendingagenry fortheperforrm
ante of the work for'which this permit la timed (Sec. 3097,21v. C.)
Lender's Name.
Lender'. Add.
Iartilythat1havereadthbapplicatio"and YatethattheaboveI f.mutlen
bcomeet. Iageretoeomplywlth all eftyand countyardlnancesend Yate laws
relating to bullding mnstmdlon, and hereby authodaa repre.enktivesof this
rytoenarupo"the abo=ntioned property, for impaction purpose.
e) agree to Indemnify an d keep harmless the City of Cupertino
alai tlkbiRtfes mmhscvst.`"dexpenses h Inanywaya a
In old 1 nscquence o(t ant of th rm16
�Q
UI I
D
SEISMIC FEE
TOTAL:
ELECTRIC
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMUMSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date RCcel t4f
AIR HANDLING UNIT (TO 10," CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IQWa CFM)
CONSTRUCTION TAX
Jggasfar of Apph.et/ or Dat
H ATERIALSDISCLOSURE
Wlllth applicant or fulum building occupant store or handle hazardous
nuterlala. e0mdbythe Cu m Municipal Code, Chapter 9.12, and the
Ikalt Yaannd SifetyC°de Noon 2553203)7
qllltheappliantor tum Wildingo pantumequ(pmentordevires
which emit haardous air cont eart.as defined by the Bay Area Air
Quality Management DI t
4Ycs o
of
havere'ad Health
a Safety Code Se reons 2555, 2553 and 25534.
l IltarnlaHealth&SotetyCode,Section�75505,2553tead2thatI[
uncle and that if the bullding does not currently havealcnanL /)cat itbmy
r®pans ilityto Ify lheonvpant of he uim Uwhish moat met
prlorto urs aCarl l tend pan
9 LC
IXI IAUSTHOOD(w/DUCT
CONSTRUC=TAXD:
HEATING UNIT (TO 100,000 BN)
Date
HEATING UNIT (OVER 100,000 BTU)es
TOTAL:
t
VU -DILATION FAN( SINGLE RFSID)
ISSUANCE DATE
O n,D,
B AR
,
: aT'35�1
'sx '. J
'
of Citne�rtiinnoo�-}� p4osj
ISSUED BY: X
BOILER -COMP OHPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 RTU)
NEW RESIDENTIAL MECH. SQ.FT.
cr ora h h est to
TOTAL:
OFFICE COPY