21332 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
21332
o Nor FG. �rooks(����e
re J L I one-
Sd
Qr �(YL SIVA 6,S T CITY OF CUPERTINO-BUILDINGDIVISION
Cor .N.: 3L� APPLICATION / PERMIT I
V_ d BUILDING-ELECTRICA1,PLUMBING-MECHMBCAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
O CJS 49.. QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: V N k Vat�e C5 OD/ PERMITISSUANCE "n
E:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LP
I herebyaflonethat l am licensed under provislan.of Chapter9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwilh Sectioa7000)of Dlvblon3 ofthe Businessand Profes doesCode,and my
I=is in fu and effect �/ PANELS
U¢nx inn — LIc.if
Date ..tractor V `< yAiMPS
ARCHITECTS DECLARATION / 2(11-1000 AMPS
p z I understand my plans shall W used as public record.. OVER IBBB AM SQ.Ff.FLOOR AREA $/SQ.Ff.
wO
U ELicensed Professional SIGNS ELECTRICAL
to t
OWNER-BUILDER DECLARATION
G, E( SPECIAL CIIICNT%MLSC
1., owinghereby alRrnthatlam01.5,B fromthe Contractors Ll¢nse Law fonthe _
O7F'a cmnt whichrequi aperion? tW Business and ProfessionseO le hnydtyor TEMP METER OR PML I T.)
P<SG countywhich requires.perMtromvrequialter, aprovGt for such
to (�
K any.signed
t.terne samt t ae Islice sed pursuant pBaeUer inions of the �C:EWER DEl�CFS�
file a signed gcens ent that he is licensed pursuant it the tion 70oro of the .bp Yr t
pOLL� si o3 ftha License Law roliceiamiCiftaptarli commenting e1srxen1on7000)of CRvb ' swim G1�VL ELE C
u 3 0
the
basis
fo the alleged
d exemption.Any viothat lation f Brumpt 0erefromany VALUATION
rr S°S the blab for the permit
su subjects
p Any violation of Section notm re any
g G� OUTLEiSSW7TCHFSFIXTUR6
applicant forapermit$500). the applicant to rnRpenalty ofnot rtnrclhan
O five hundred dollars hepr. ;/ .j � HEW RESIDENTIAL ELECTR,` SQFT.
A STORIES TYPE CONSTRUCTION
1,as owner of the property, l he em tare in with wages r their sole
�%Q compensation.willdBasin ...dhe oxf.l..Cade The ot C.sa eeEedor offetud for N N/
�p sale(Sec.7004 Bu.innaand Profesaloru Code:The ContractoJeW¢rue law
�$g does net apply to an owner of property who Wilds or Improves``thersoryand OCC.GROUP RES.UNITS
who docs such work himself or thrmgh FIs own employees,provided that each
Improvements are not Intended proffered for sale.IL however,I(hebuilding or TOTAL:
improvement issold within oneyearofcompletlon,the owner-bulklerwill have
thrden of provingthat he did not Wild orlmprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODWNE APN
UI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7099,Business and Profession;Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN k VLN'E-WATER(EA)
Wilds or Improves themon, and who contracts for such projects with a FEE SUMMARY
co,➢_tIamo,(,)licanned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec B A P C for this reason -
OUTSIDE FTL�S
DRAINSFLOORROOF,AREACOND. SANITARY Y_ N_
• Owner Date RECEIPT
WORKMAN COMP INSATION DECLARATION FD(TURE4 PER TRAP SCIi00L TAX Y_ N_
hereby affirm chat I have a certificate of consem to eel(-Inwrc,ora RECEIPT Y
Iflateof Workera'Compevation/lruuran¢ora certified!copythereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N_
RECE
-0
3888.Lab C3 WC_ 6�4ra
1'oliry Y DING DE p
Com env ledr I L � GAS EA.SYSIiMVER4(FA) BUILDING DIVISION FEES
�CertiOe ropy is heed witht .city GREASE/BVDUSTRLWASTEINTFRCEPTOR PLANCHECKFEE
Ceriillcd copy b filed with the city Inspection divlelon.
CERTIFICATE OF IXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER SAMTARY-STORM EA 200h1' Date Recei t#
(fhb section need n¢be completed if the permit b forone hundred dollars
(St00)orlceW WATER[iEATFR W/VENC/ELECIR ENERGY FEE Y_ N_
I certify that N Ne periormsn¢of the work forwhich this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING
Workces'Compensattonlaws of Californb. Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Raeei t#
Z U NOTICETO APPLICANT.If,ofter nuking this Certificate of Exemption,you
should become subject to the Worker.'Comperurtion penbiom of the Labor TOTAL:
N Cody you most forthwith comply with such provisions orthis permit shall be BUILDING FEE
C j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
lL Ihereby afBumthit them is a construction leadiagagency for the perform TOTAL: ELECTRIC FEE
D Z an¢ofthe workferwhichthb permit is toued(Sce 3097,Clv.C.)
00
lender:Name PLUMBING FEE
LL F Iender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Iuniry that l have read this application and state that the above Information ��Tp�
0 W Ismreact.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE \�W FEES PAID:
r (L relating to building construction,and hereby authorize representatives of thin
r N city to enter upon the above-mentioned property for inspection pu rpose.. ALTERORADDTDMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu pedino Date Receipt#
L) agiihothatailiticepcigmen c, caste and expense.which may in any way... AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ainet ea ¢Of the granting of this p milt.
°9e / _ � O AIR FIANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
Igiut o /Contractor Data IXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATF.RI DISCLOSURE
Will the applicant or future building t store or handle havn)ou. HEATING UNIT(TO 100,000BTLB Date Remi t#
material as defined by the Cupertino Mu I Code,Chapter 9.12,and the
Health and Safety Cod Ioon25532(a)7 HEATING UNIT(OVER 10,000 BTU) T. L: A�
M Yes PTF1u,N g
Willtheapplicant or tore building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSU Ill TE
which emit havrdous air contaminants as defined by the Bay Area Air _
Q1Qi(nlyy Management W BOILER-COMP OHPOR 100,IXD BTU) O C I z s 1990
Yo
read the haza omaterialsrcquim, enNunder Chapter6.95of BOILER-COMP(OVER lffl WO BTU)
the Callfornla Health fety Code,Sections 25505,25533 and 25539.1
and codand that if the build Ing does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FC.
responsibility ro notify the occupant ofthe requirement.which at be met
prior oarscora Certificateofosupanq.
_�s J&
Owner or auherimd agcn Date
TOTAISSUCDBY:
L: �.C]
OFFICE COPY