21751 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProtect Identification PERMIT NO.
nwlainnaa .e:
1 es I V`L � 21751 g751
nems aces: one: A A
CITY OF CUPERTINO-BUILDING DIVISION q 1
ContrartnrsName: pp� Lie.No APPLICATION /PERMIT
LJ_ �F300 y} BUILDING-ELECTRICALPLUMBING-MECHANICALCATEGORY CONTROL
Arc ted/Ggineer. LIc.N
'M x—'rN.��- Il�lac,-o.--. 1 BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE / ,�/
Address PERMITISSUANCE I Q �f
1'11.6 Mff
LICENSED CONTRACTOR'S DECLARATION j �1 LJ
19/
I hemby afflrmthat l am licensed under provisions of Chapter9(mmmenc 'APPLIANCE4RESIDENTfAl JOB DESCRIPTION
Ingwlth Sect1on70D0)of Dh,Bdon3ofthe Busineasand Professions Cod,and my
Ifcensc Is In full fo d effect. PANELS I
License Cha=Llc.0 LF3UOq� 7 Y O
Date Contractor UP TO 20DAWS
ARCHITECPS DECLARATION 201.10)GAMPS
$/
qG m0 O I understand my plansplansshall be used v public records. OVER 1000 ANIS 'I SQ.17.FLOOR AREA SQ.FT.
a Q of Licensed Prfesdcmif SIGNS ELECTRICAL Z rI
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MSC J c(
,1.., , 1hereby affirm that lam exempt from the Conradoes License law for the
following reason.(Section 70115,Business and Pmfealona Code:Any city or
countywhichmqulrtsapen ttom-.( cC,alter,lmpmv,demolbh,ormpalr TEMP'METERORPOLEINSr.
anystmdumpriortoibbwance,ahorequlrestheappliantfersuchper tto
7ryG{,w POWER DEVICESfile a signed statement that he Is licensed pursuant to the pmvenov of the
F.,ElOS sbo 3 ofthe Businesractor's Licenses Law
PMealov Code)orter 9 hatt heb eth umprtton M1�fmmand SWQ,1MINGIWL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7m15 by any� OUTLETSSN7TCFIFSFl%Tl1RF5 applicant Fara pemmltsubjeets theappllcant too civil penalty f not more than
five hundred dation($500). SQFr, STORIES TYPECON'SIRUCTION
.R NEW RESIDE TIAL ELECTR
7
compensation
s owner of theproperty,d my employeewith wages thelesole
om(See.7lon,will Bothe work and the structure b not Intended or License L for
p vie Sec. pply toBusiness
nowand f property Code:The Conteaorimpnors License Taw
�,15$ does net apply toanowncrorpropertywho nbuild.
emorimpmovided thatand such OCC.GROUP RES.UNITS
EE.. who does such provementsamwork hlmxnded olf or rwghedowne.11,ho evertiebuildingor
Improvementsart not Intendedorofreredforsale.It,howeveg deer ill have TOTAL:
Improvementueokl withinoneyearofcompldloR the owner-bu0derwlll have �
thq_I;urden of proving that M1edidwt ildorimpmvelorpurpomofsale.). QTY. PLUMBING PERMIT FEE I Flppp ZONE ApN
L1 I,as owner of the property,am exclusively=trading with licese
nd
contractors to construct the project(Sec.7falk Business and Pafesslov Code: PERMIT ISSUANCE
The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN A VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptojeets with a
ctt.(act (a)Ilanxd pursuant to the CmArader's License Law. - 1 FEE SUMMARY
LII am exempt under Sec B k P C for this recon BACK FLOW PROTECT.DEVICE OUTS I DE FIA S
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N WORKMAN COMPENSATION DECLARATION I RECEIPT#
❑i hereby sones that 1 have a cert u a c of consent cl copy
thereof
ora FlXTURE4I'ER TRAP SCHOOLTAX Y N
Op 380i,Lab of Workers Compevatlonlvurance ora certified appy thereof(Sec. RECEIPTN
3800,Tab CJ GAS E.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy 8 i RECEIPT#
GAS E.A.BYST- OVER-OVER (FA)
Com any BUILDING DIVISION FEES
CCertiliea copy is herebyfamished.the
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�eemnnea empty�filed with the dry Inspection division.
CERTIFICATE.OF PXEMITION FROM WORKERS' CREASE TRAP PAIID
COMPENSATION INSURANCE SEWER-SANRARY-STORMEA.200Fr. DatC Rccci IN 15.50
(rhissectlon need not be completed lithe permit is for one hundred dollars
(tt0metifca3 WATERHFATERW/VENT/E.ECTR ENERGY FEE Y N
I¢not that In any pehe rson
nce in any m worknner forwhl become
penult is bo ed,the I.
I shall not employ any person In any manner so u to brooms arbjed to the WATER SYSTE.f/.IRFATING,
Workers Compensation laws of California.Date WATER
ileart
Z Q NOTICE TO APPLICANT.If,after making thisCertillateof Faemptlon,you NEW RESIDENTIAL PLMB. SQFF. Date Remi tic
should became subject to the Workers'Compevb
ation provisv of the Labor TOTAL:
N Code,youmust forthwith comply with such provisions orthlspermit shall. BOLDINGFEE
`> deemed revoked.
t (L G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE ��.35
Z once of the work for whleh this permit is Issued(Sec.3097,Civ,C.) TOTAL:
o2 Iender.Nam 11 PLUMBING FEE 70.35
LLh- ]ender.Admea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE '7Q.35
O W' (certify that l have read misapplication and state that theabove Information
1 Is correct. to omplywith aBdtyuWcounty ordinances
mpmwand date laws PERMIT ISSUANCE FEES,- PAfA: �Q�Sb
} cityt oenterupon the
coabovi, oganadpropauthorizespetionnpurposof tub •I `y.Y�
Z cir(W09ereetosae,Imicradlyaned property for inspection purposes ALTER ORADDTO MECH. F
— (P.'e)agree tc ssIdg IndcmnAl an d keep..rhea the in.of Cupertino ' Date Receiptk
against li idCit s,judg"ein ,ofth expenseofthf.mayinsnywayattme AIR HANDLING OMT(TO l0,W0CSM) SUBTOTAL'
against mid City in ronsequence o(the grantingdthis permit AIRHANDUNGUNIT(OVFR 10,MCFM) CONSTRUCTION TAX
SlgnatS.o A Ilea)/Cmntrado / to IXHAUS'r HOOD(W/DUCT) ONSTRUCTIO T "y�JpAM:
HAZARDOUS�ATERIALSDISCLOS E �—ql �7Is
Will the applicant or fumm building occupant store or handle haeamlous HEATING UNIT(TO 100,M0 BTU) 'Date RCCCI ttq
rnatnlal as defined by the Cupertino Munidpal Cod,Chapter 9.12,and the
Ilealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BM � IAL:
E] Yes M No
Will the applleantm Mears building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) S ANTE
hichcrdt baeardous air contaminantsas defined by the Bay Area Air �� `} 4 yI I
lily Management District? BOILER OOMP 0HPOR 100,0(9 BTU)
u�LJ Yes n No
(have read tneF'3Ow materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,IX0 BTU)
the Califomla Health 6 Safety Code,Sections 25505,75533 and 25534. 1 �
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENfIALMECA. SQ.FT.
responsibility ro notify the occupant of the requirements which must be met
prior to Lauanm o!a Ccrtlficate e(Ocupanay. ,)
1�1Ic
Owner orawha set agent ate
ISSUE DB Z'
TOTAL:
OFFICE COPY
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