21052 (2) APPLICANT.TO FILL IN IN WITHINAED LINES - USE BALL POINT PEN ONLY
Building Project Identification r PERMIT NO.
Building Address:
2348 rc,rroaT o, 21052
rUwater.Name: one: I -
PjjQ& J a CITY OF CUPERTINO-BUILDING DIVISION p
Comrect'rs Name: - `. - LIC.No: -APPLICATION /PERMIT C 0
BUIIDINGELECTRICAL-PLUMBING-MECHANICAL CA RY CONTROL
�` ArchltM/Engineer. DVLq fl.[ Llc.No '
Ojai
I'" o �' .Qir l,y l ��ELECTRICIt,
RM—IT
`�`-0,1 FEE ' ''BUILDINGTERMIT,I NFO'
aM
Address:s• +�Mc��>A{/s��—��� O PERMIT ISSUANCE
LICENSED CONTSRf OR'S DECLA ATION E El El
I hereby affirm that l am licensed under provisions of Chaptera)(Cornmenc, APPLIANCESRES76ENf1AL - JOB DESCRIPTION
Ing
soveis full force
efeon3ofthe Businessand Profusions Codc,antlm �� � ;
license le In full force and effect. PANELS h �T
License CUss Com `r C E1 (L
Date Commerce '
ARCHITECTS DECLARATION 101-1000 hMPS I'
qwqI�re[O I understand my plsoa shallbe used u public records. - OVER IOW AMPS SQ,Fi.FLOOR ARIA $/TQ.FT.
E `j Licensed Professional , SIGNS ELECTRICAL I /r1
GGG 6 ro OWNER-BUILDER DECLARATION / 1/
G �7 SPECIALCI(CUfT/MI "
P, � Ihercby affirm thatlam exemptfromthe Cont tactors License Law for the
0 qqqq following reason.(Section 7871.5,Buiness and Professions Code:Any city or b
F`~ cmntywhlchmqulmsapermittommtmd,altee,Improve,demollsh,ormpair TGIP.METER OR POL
`4 3Q anystmcwm prf rto Its twaance,atw requires theappliram(orsuch permit to
0�U file a signed statement that he is licensed pursuant to the provisions of the POWER DEVIC
O ec Contractor's License law(Chapter 9(Commencing with Section 7000)of Dlvl-
„-,�0 slon 3 of the Business and Pro(cadona Code)or that he is exempt therefrom and SWIdhIN F1.E C VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE IiPSH PS {j V 0
pp� fiveapplicantdred apermit
rs($S eds the applicant too civil penalty of not more than A (, O.''
eaR fivehundreddollarshepr. NEW PNIIA L- C/
❑l,asowner of theeworia,aormy employees inwithwagesas rthelesale 'ET' STORIES 'L'I'FE CONSIRUC'I'ION'
7
compensation&c.704n Biltdosiaand k.andthesC de:TheC Contraintendctors
oicense d for
Law
S O sole(Sec.7054,to alnow and f property
rope ty Code:The Contractors Untrue law
7�$ doesn't spplytoakhonsiner o(prough hisobuilda nemptirimproovidedves reoryand - OCC.CROUP RES.UNITS
0. whodoements.suchwnet Intendedorough hisowne.If,hoes,er,thedthatsuch
improvementsereno[ithindneyearferMfor sale.If,h er-hugder llIhaveding or TOTAL:
Improvement bsold within oneyearo(complMion,thcowner-builderwlll have '
th,�uerdeo of proving that he did not build or improve for purpose of sale.). QTY, PLUMBPE
ING RMIT'' "'FEE FLOOD ZONE APN
LJ E,as owner of the property,am exclusively contrading with Ilmnsed PQ(MITISSUANCE
Contractors to Construct the project(Sec.7054,Business and Professions Code:
The C'ntmcnaii License Law does net apply to an owner of property who - ALTER-DRAIN&VENT-WATER(EA)
1 Wilda or Improve thereon, and who Contracts for such,ptd
nJea with a 'xtY. FEE<SUMMARY
I arterial licensed pumuant to the Contractors License Law, SACK FLOW PROTECT,DEV(CE
LJ I am exw
empt under See. B &P C for this iean
Owner One DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ NOUTS I �
s� WORKMAN COMPENSATION DECLARATION RECFIPTM
{❑I hereby affirm that I have a mrtiflcate of consent to self-Insure,or a FIXTURE&PER TRAP SCHOOLTAX Y N -
7mr. �T{{,, oediflLabC.) rken'Compe�uatlon lruurance oracertlfledcopythere'((Sac. RECEIPTN
`";,yyyA''38W,lab CJ CAS EA.SYSTEM-1 INC.40LJTLETS PARK FEE Y_ N
Po11ry X CAS EA,SYSf'FM-OVER 4(EA) RECEIPT A
IfflanCo y BUILDING DIVISION PI:[S
Cenlfled Copy 6 herebyfinished.the city - CREASE/INDUSTRL WASTE INTERCEPTO PLANCHECK FEE
CertlflN Copy ls filed with the city inspection diviNon.
CERTIFICATE OF EX EM PTION FROM WOR KERS' GREASETRAP pAlp�-- sta
COMPENSATION INSURANCE SEWER.SANTTARY-STORM EA.2001— Date Rewi t#
(This section need nut becompleted lithe permit ls(Drone hundred dollars
($10fimless') WATER HEATER W/VENT/ELECTR ENERGYFEE Y N' —
I rertlfy that In the performanm'f the work forwhich lhls permit is lsevcd, —
I shall not employ any person In any manner so as,to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of CaI fomb. Data PAID
0 ZApplicant
Z 0 NOTICETOMPLICANT:ILahermakingthb Ccrtlflratebf Exemption,you NEW RESIDENTIAL PLMB. SQ.IT. Date Remi t#
Fshould becomesubjed to the Workers Compensation provisions of the Labor ' TOTAL:
N Code,you must forthwith Comply withauch provisions orthls permit shall be BUI O
W j deemed revoked. '
L�INC TEE
OW. CONSTRUCTION Ions LENDING AGENCY SEISMIC FEE (_
!hereby orkfo'hat there ba Cordt is id lending agency 097,Cl(on)e perform TOTAL: ELECTRICFEE
� Z ..co of the work(ar which thio permit is bided(See.3097;Civ.C.) '
OO Lenderawme - - , PLUMBING FEE
LL F lender's Address - QTY. rMECHANICAL'PERMIT -.t E1 MECHANICAL FEE .
0 W - I conifythat l have read thisappllotionand statethat the above Information •
Niscorect.IdgreetoComplywithallcityandCountyordinancesand&ate laws PERMITISSUANCE FEES, 1'J 15-1V 2z} relating to building connection,and hereby authoriae reprexntatives ofthis
[� Z city to enter upon the above-ment7oned property for Wpectlon purposes. ALTIRORADDTOMECH. Dale RCCCI t#
L.I _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liablllt es,judgments,cosband expenses which may In an ya¢rue AIR HANDLING UNIT(TO 10,000 CFM) SIIBTOTAL:
agalto ad 1 Inconseque a grants of this permit.
Qo AIRHANDLING UNIT
lo,lza cr•M) CONSTRUCTION TAX
Sig.mreof AppBnrit/C'm.el —1 D e EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle haaardom HEATINCUMT(TO100,000 BTU)
material as defined by the Cepedin'Municipal Code,Chapter 9.1$and the Date Reeel t#
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 1D0,001)BTU) TOTAL:
❑Yea MN.
.lea.em Will the applicant or future building occupant use equipment or devices - VPNTTLADONFAN(SINGLERESID) ISSUAbCE DATE _
which emit havrdous air comaminantsas defined by the Bay Area Air .6?'d+`'
�itotlity Management District? ' - BOILPR-COMP 3HPORIW,000BTU)
Yu i+'.❑No
I'� 2
! have mad the haznrdmis materials requirerents under Chapter 6.95 of BORER-COMP(OVER 100,000 BN) O v 7g9U
.y, ..) the California health&Safety Code,Sections 25505,25533 and 25534, 1 MA
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. '.Q.IR.
responsibility to notify the occupant of the requlremants which must be met
prior to issuance of a Certificate o(Occepanry. City of el1(1 n d,Inn
Owner or authorlved agent Data
TOTAL: ISSUEDBY: C `
OFFICE COPY
- f