21707 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bull din Project Identification Reation U— -3� G POMT NO.
liullding Address: l�
..1 1 .� � S Q 9(' T_ C(Lti ,kC h Z� LTl Z� 707
crs a one: A A A
CITY OF CUPERTINO-BUILDING DIVISION
nra.t.r Na APPLICATION / PERMIT
t d BLTLDING-E.ITTRICALPLUMBING-MEGHAMCAL CATEGORY CONTROL X
Iteci/• gine Mj'�
L R I U QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Adds
PERMIT]%UANCE
LICENS[D CONTRACTOR'S DECLARATION
Ihemection7000)oOry Vcansedundusineslalansof.l.r.0(mmmm APPLIANC6RESIDENTAL JOB DESCRIPTION
IngwehIn fon 7000)of Dl died. oflh<BusinesundPro(mlonoCode,and my
license Is In full( anddied. / �fD�� PANEIS
License Class LX/o L/
Date Contractor
ARCHITECTS DECLARATION 701-1000A.AIPS
0I I understand my plans shall be used as public records. OVER]000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
4c,,uU[ Licensed Prof.ional SIGNSELECTRICAL
<<w OWNER-BUILDER DECLARATION V �I1 v1O r
rna reit: SPECULCIRCUIT/MI9C `
4'yd 7, Thereby afRnn that l am exemptfrom the Contranor's License Law for the
'� following mason.&dlon 7031.5,Business and Professions Code:Any city or
county which requires a permit to construct,alter,Improve,demuiIsh,or repair TEdP.METER OR TOLE]NST.
'< anysbuctumpr rtolbbouanc,aLmrequlnstheappbantfarsuchpermltto POWER DEVICES
�a O file a signed statement that he 1s licensed pursuant to the pmvbioru of the
�Du• Contractor.Llcerue Law(Chapter9(commencing with Section 7000)ofDlvl-
O fn SWE.SMING POOL ELECTRIC
the basis for
the
Pm(ession. Any violhrtheIs Seem thenfmm and VALUATION
3 the boob for the alleged exemption. Any violation of Sealant 7fA15 by any OUILETSSWITCI E FIXRIRES Y �� / .
appVnm fora permit subjects the appbcant to a tivll penalty d na monthan G
t; five hundred dollars(5500/. - I —
R NEW RESIDENTIAL ELLL\ SQ TYPE CONS'IkI1CTION
❑1,as owner of the property,or my employees with wages as their sole -
k 6 compensation,willdothe work and thestructure is not intended or offered for •� t ^
5 O vie bee 7044,Business and Prdmlom Cade:The Contnctars Limnse Uw % Xaxis 4 ,K`
does not apply to an owner d property who builds or Improves thereon,and _ igCC�CRO RIS UNITS
E€.. who doesnuch work himself orthrwgh his ownemployees,provided that such Y.V7
Improvennenb are not Intended oro(fered formic.If however,thebulldinger DATE TOTA
improvement Is sold within ane year ofmmpletio,the owner-builderwlll have
th9.�urdenofprcv1ng that he did not build orlmprove forpurposeofseb.). QTY, PLUMBING PERMIT FEE
Lf 1 as owner of the property, FLOOD TONE APN
p perry,am.7044,Busi contracting with licensed PERMIT ISSUANCE
The actorsto construct thewdoe(Sec.704EBusln owner
of
Code:
The Contractor's tmp Llmnx Lw and mat apply to an owner p property who ALTER-DRAIN VENT-WATER(EA)
Wilds t r improves thereem,pursua and who contracts for such p.ojecb with a FEE SUMMARY
,�¢tfan.r(sexempt under Sent c.
theContractors License Law. BACK FLOW PROTECT.DEVICE
cu'am exempt under Sec. B &P C for IhIs noon -
DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT
f WORKMAN I have a COMPENSATION UEC RATION FIXTURES—PER TRAP SCI IDOL TAX Y N_
❑T hereby affirmorken that 1 have o mrtlllata of connect to.pytnmm,or RECEIPT'X
certlflabC.Workere'Comperoatlon Wurance.race :Tied copy themo(LSec. GAS EA,SYSTEM-1 INCA OUTLETS PARKFEE Y - N
Pdlry Y RECEIPT N
Comany S V.lYO PC.�F•t GAEA.SYSTEM-OVER 4(EA) BUILDINODIVISIONFI[ES
�certVled copy is hereby tum
®Certnied copy Is(fled with theecity
Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ity
CERTIFICATE OF EXEM PTION FROM WORK ER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARY-STORM EANOFT. Date ReC i t#
(Thissection need red be completed if the permit b far one hundred dollars - . ' �
(51WtnifytJ WATER HEATER W/VENT./FLEC'R ENERGYFEE Y N
s l adl(y that In thepersonIperformance ny marrhe work as to becomh this e
esrmt is booed,
1 shall not employ any perms In any manner m as to become abject to the WATER SYSTEM/TRFATINC
Workers Compensation Laws of California.Date PAI D
O Z Appllant NEW RESIDENITAL PLNB. SQFT. Date Recti t#
Z O NOTICE TO APPLICANT:If,after making this Ccmflate of EsemFion,you
should become subject to the Workers'Compersation provisions of the Labor TOTAL:
~ N Code,you most forthwith complywllh such provIslonsorthb pemdtahallbe
� j deemed revoked. BUILDING FEE
,•••a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthO then b s construction kion.,agency for the perform- ELECTRIC FEE
Z ante of the work for which this permit Issued bee.30YI,Civ.C.) TOTAL: ^
92 1<nder's Name J PLUMBING FEE ICJ O•
LL F Le.der3Addres. N/ ")' QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W _ 1 rUtyth.tI ham rc.dthbapplla .nand atatethattheabcvelnfornution
scorned l agreetocomplywlthall cityand muntyomllna.cesand state laws PERMIT ISSUANCE FEE$P D:
>_ N elating to building construction,and herebyaveatlosmoe......nw—,ofth, ( I r /aCC
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MFGH. paI ReCe1Pt#
_ Me)agree to saw,Indemnify an d keep harmless the City of Cupertino
against liabilities,judgerru,"itand expenxawhlch may inanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
againat said Clty consequence of the granting d this permit.
AIR HANDLING UNIT(OVER 10'f CFM1 CONSTRUCTION TAX
Signature of Applico/C..tractM Dan EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS IIISCLOSURE
Will the appliont orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTL) =I-p-lie-' ReCei f#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
s Iir.Ilh and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: o
❑ Yea MIS.
Will the appllam orfutumbu ilding occuptnt use equipment or devices VIINDATION FAN(SINGLE RESID) ISSUANDATE
which emit h..rdous air moil minarets as defined by the Bay Area Air {i-� -C
Quality Marugement District? BOILER-COMP O4Er OR 100,009 BTU)
Y II��No
lave read the havrrTo..manriala requiremser,underChaper 6.95 of BOILER-COMP(OVER 100,000 BTL) FEB 14199:
the California health&SafetyCod,Sailors 75505,75533 and 75534. I
undc.t.nd that if the building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the oceopant of the nquireme. which must be met Caiv
prior to Issua�nsce d a Cenificate of Oavpanry. r11ne•-
Danerora �
uhr agent / s
TOTAL: ISSUED I .
OFFICE COPY