21563 (2) PLlCANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
_ . Bulldln Praia"Identification PERMITNO.
Building Address; 21563
d 24 q nti ! lleA� /9XALIp
rasesone:
fib �3 CITY OF CUPERTINO-BUILDING DIVISION
c ntrador'a ante' .r Mr.No: APPLICATION / PERMIT
! / LOQ// L/� 7 yS BUILDING-MBCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
Architect/Engleeer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. _ PERMITISSUANCE ❑ ❑ 1:1V
LICENSED CONTRACTOR'S DECLARATION �[j
I hereby affirm that l am Beamed under provisions of Chapter 9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sectbn7000)otDel1 o1 ofthe BupnemandPro(emlansCade,and
Ikenar Is In ha o d dfect. 4 .5'
PANELS
LlcenanC6m LIe M-�`JS�.
Date I Contractor../a /�I NahS Cs/r`Qa1UP TO 2DO AMQ�S
ARCHITECTS DECLARATION 701-1000 AMPS
I understand my plane shall be used m public records. OVER 1000 AMI'$ SQ.ET.FLOOR AREA S/SQ.FT.
q� qO
'rG Licensed Pmfessional - SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CBiCNT/MLSC
Z Ihereby affirm that am exempt from the Comeadols Llcanae Law for the
K� qqq following reawn.LSectlm7m15,Busmesaand Professions Code:An a or
I-'ry cvuntywhkhrequirmapermlttommtmct,alter,bnpmv den lish,ermpalr TEMP.METER OR TOLE INST.
anystmcture Prkrto its lsulance,alw mquieatheappBtant for such permit to
file a signed statement that he is Bernard pursuant to the provisions of the POWER DEVICES
O u,I'ii Contracict'sLicense Law(Chapter 9(commendngwith Sectirn7000)ofDivi-
30 pon3 ofthe Business and Prole,slonsCode)orthat he laeumpt therefromand SWNtMING POOL EZ C VALUATION
'g the basis for the alleged exemption. Any violation of Section 7031.5 by anyL
papplicant for a permit subjeRe the applicant to a civil peraltyof not rmorethan OUTLE
five hundred dollars($BOOL
1,as..at of the property,or my employees with wages ae their sok WR D nti AE ELECTR SQ.E7. STOW-S TYPE CONSTRUCTION
compensation,willdothe work,and thertructure knot mtendedoroffe for �Iti
q mk(Bec.7044,Buelne..and Professions Code:The Contractor's Ller w t
$ does not apply loan owner of propettywho Wilde or Improves them a d OCC.CROUP RES.WIT'S
whodoessuchworkhimseBorthreugh hlaownemployees,provided that h
Improvements are not intended reoffered formic.If,however,thebulldk or \� a TOTAL:
Improvementbmldwithlnoneyearofcompledon,therwner-Wlldat ill ve
t4litpu
den of proving that he did not build or Improve for purpam of m . PLUMBING P R FEE
LJ 1,as owner of the property,airs exclualvely mnitading with Ilca ae PLOOD 7ANE APN
mntradora to mmlmct the project(See 7064,Bus lnem and Pna(emlrns Cod PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of propeity wh /AL'TTR-DRAIN •WATER(EA)
Wilde or improves thereon,and who contracts for. r ptrto w e FEE SUMMARY
lot(,)Bernard put nuantmthe Crnt.dm'sLlernar Gw. BACK FLOW T.DEVICE
LJ I am exempt under Sec B 4 P C for thio mown
OLITS I OF FEES
DRAIN ET.00 SANITARY Y N
• Owner Dale R ROOP'' `a•C0�' RECEIPT=
WORKMAN COMPENSATION DECLARATION PER TRAP SCITOOL TAK Y N
QI hereby affirm that I have o lmificate of consent d self.insom,ora RECEIPT X
er0 L
ab
o(Worken'Compensatlonlnsuraneror rtificd mpytherm!(Sec. GAS EA SYSI•Q.SI INC40UTLETS' PARK FEE Y N
ab C.) I
N_ {..0�- g a ^ Q RECEIPT X
pA7�Y�ha�.S GAS EA.SY9'I'FM-0VERd(PA) BUILDING DIVISION FF.Eg
ertified copy k herebyth thehed. � CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE mpypfiled with the city,inspection division. , -
CERTIFICATE OPO(EMPTION FROM WORKERS' GREASE TRAIT PAID
. COMPENSATION INSURANCE SEWER-SAM.I•ARY-bTORM FA pOFC Date Recei t#
Ghlsseciion need not be completed lithe permit r dt la foe ow hundred dollars
($100)or hem.) WATER HEATER W/VENT/ELECTR - ENERGY FEE Y ' N
I mdlfy that in the pedm
ounerrf the work for which this permit is issued, —
I shall not employ any person In any manner w as to become subject to the WATER SYSIETI/TREATING
Workers'Comperustlon Lawsof Callfomla.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recel tq
Z NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you
Fshould beurns.0ject to the Workam'Compensation provisions ofthe Labor 'TOTAL:
N Code,you at forthwith comply with such provisionsrrthisperralt shalib.
deemed revoked. BUILDING FEE
_
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby afOrmthat then Is a construction lendingagency for the perform
� Z arm of the work!car which this permit bIssued(Sec 3W7,Civ.C3 TOTAL: ELECTRIC FEE
00 Iendar',Name PLUMBING FEE
LL F Lender'sAddrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ierrtlfythatl love read thkappllcatbnand ata tethattheabovelnformatlon
lscorma.I agree tocomply with all cityand county embarrassed pate laws PERMIT ISSUANCE rX.CC FEES PAID:
>. f1 relating to building construction,and hereby authorize representatives of this
I" U) city to enter upon the abovcmentkned propertyforbapectlonpurposs. ALTER OR ADD TO MECH.
V,Z Date Recei ttf
— in gree b cove, ants, 'and keep harmless the u%.at Cupertino P
again abllitles,judgmenb, and expenses which may In anywayaccme AIR HANDLING UMT(T010,000 CFM) SUBTOTAL:
agai old City in • of the granting of this permit, . AIR HANDLING UNIT(OVER 10,ODOCIM) CONSTRUCTTONTAX
13-2
S natum ofAplicant/Contractor Data EXHAUSTHOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fewer building ravpant atom or handle hazardous HEATING UNIT(TO 100,000BTU) �a� Date Recei tp
material a,defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: I s .0cy
Fj YesNo
Will the appbrant or tore building occupant use equipment of devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air conta Mnants as defined bythe Bay Area Air
Qua Oty Management Distt(rt7 BOMER-COMP OHP OR 100,000 BTU)
1�Ym I�I No PAL!/\ .
have read Health
a nus mpedala lons2menb5533 and
6.95 of BOILER-COMP(OVQt 100,0000N) �rY6<r
the er Oand t Health building Safety Code,Sections ntly h ve a to ad,that i I ^E C 1 3 1
understandytohat if notifythercupa ns of the currently tenant that]rimy NEW RESIDENTIAL MECH. SQ.ET U (IQ:'E
rmpoto Issuance
ce not Bytheoccupantofthe requirements which must he mM sTs7{8
prior to Issuanre of a Certificate of Occupancy. ,
Owner or aulhorred agent Datel��L{{y1R�'Qf em sane(
TOTAL I v� ISSUED BY: "_
OFFICE COPY