21866 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building AddPI(RMITNO.
ress: V.I ,
21866.
eer. time: •
SIfl1O/J GH'( E:A' �e CITY OP CUPERTINO-BUILDING DIVISION �7
G.....r.Name: Lie.No:
APPLICATION /PERMIT J f/ -
ArchltecTK�EI�r/ydn11``� ✓ BUfLDING-. L . RCAPLUBNGMCHMCAL , CATEGORY .
Lie.No -
C OtJB
, _ BUILDING PERMITINFO
QTY ,ii t It, E.0ATC,PERMIT FEC
Addroge 0,41%K6 � V1p ,sj4&
• "
(a�� PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPUANCFSRFSIDENI'IAL JOB DESCRIIPDON
ingwllhSecilon 7000o(fAvlalon3ofthe Buslnessand Proleselon.Code,and my .'j'' ^ —� ^
license I.I.full force and effect - PANELS
se n I..I�
LicenClaLie R A S �
Date - Contractor IM TO 200 AM5
ARCHITECT`S DECLARATION 701-1000AMP5
W7, I understand my plans slug be used as public records. OVER1000AMPS SQ,FT.FLOOR AREA $/SQ.Fr. '
qqF±± Ge mL I N
E d 0 Licensed Professional SIGNSELECTRICAL .
�<<6 OWNERBUILDER DECLARATION SPECIALCIRCUIT/MISC
Ihercbyatfirm that[ace xempt(rothe Contractor's License Law for '
oo following reason.(Section 7031.5,Business and Professions Code:Any city or P U T R
F z F TEA4P.METER ORPOLE INST..
county structure
requlroa permittorowtmuires the
eaprocant forolbh permit
to
O .n any stmdure oomortr to tshat her also requlrersuantio tholforsulonsof dtto
POWTR DEVICES `�
TNG s. (Ile a algned statement that he b Ilcensd punuant it the tion 70 ) of the
�., Contractor's License Law(Chapter9(mmmandhg with Section 7000� o(Dlvl- ATION 0 Divi-
sion 3 ofthe Business and Prefessbro Cod0orthat he b exempt therefcumand SWP4MING POOL ELGCTRIC '
O the balls for the alleged exemption. Any violation of Section 7WIS by any UTLETSSWITCHESFU(TURES ^1 //'''' ��s'y•�
applicant for a permit subjects the applicant to a civil penalty of not more than g17�. SCJ
flue 1,as
dollarshepro NEW RESIDENTIAL ELECTR SQ.Fr. STONES TYPE CONSTRUCTION
compensation,
I,as owner will
the property,or my employees with wages r there sok
sole(Sm744,Rastrutheworkandthe structurebootntract r or offered for _
9�O sale(See 7(R4,Buelr�en and Pro(enlors Code:The Contractors License Taw _ '
F{$� does not apply to an owner of property who Wilds or improves theme,and OCC.GROUP RIS.UNITS
who does such work himself orthrauna
gh hlsoweemploye ,provided thatch -
Improvemcnts are not Intended orofleredfor sale.If,however,thebulldingor TOTA .
Kimprov fit Is.td withirmeyearofcompletion,the owner-Wilderwlll have „ ,
edamof pmvingtha he did not build or improve forpurpoaeofsele.). 'QTY. 11', PERMIT' " ,{. i FCE,'` FLOOD ZONE- AI>N
e owner of the property,am exclusively mntocting with Ilcened PERMIT ISSUANCE r1 sn
ntn to rorsWctthe project(Sec.704q Business and Professions,Code: 4CJs+
The Contractor's License Law does not apply to an owner of property who ALTERDRAINk VENT (EN
build.or Improve thereon,and who contracts for such Pt I cts with a - - FEE SUMMARY"
cgaractor(s)licensed pursuant to the Contractor's License Law. - .F .I
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE `
DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
OWner•' Date RECEIPT
WOR"IAN COMPENSATION DECLARATION FD(•fURES PER 7.RAla '� SCHOOLTAX Y N
❑I hereby affirm that I have o ce lificideInsurance
of consent to copy
or RECEIPT a
certificate of Workers Compewtionlvuranceoracertifled copythereof(Sec. 1 GAS EA.SYSTFN-1 INC.4 OUTLETS "�� PARK FEE. V N
38
W,lab CJ l RECEIPT'a
Policy R GAS EA.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION ITES
�
Certlfied copy is hereby fumbhed. GREASE/iNDUSTRL WASTE INEPTOR PLANCHECKFEE
FiCertlfied copy is filed with the city Inspection division, TERC
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP x PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date R.l Q
(This seti.n`need not be completd if the permit bfor one hundred dollars pf# / ��
($100 .'hoo.) t I WATER HEATER W/VENT/EL.1CTR ENERGYFEE Y N
I modify that in the performance of the work forwhicb this permit is Issued,
I shall not employ any person to any manner so as to tierome subject to the WATER SYSTEM TREATING
Workers Compensation Lawa o(Califomia.Date / PAID -G3
Z.Z Applicant NEW RESIDENTIAL PLMB._$Q,FT. 'Date Remi [# JO�
O NOTICETO APPLICANT:!Leter making this Certificate of Exempllon,you
sh.1dberome.bim t.the W.,rt .'Compewtlon prvvlalmuoftha Labor . TOTAL: tto
� NCde,you most forthwith comply with such provisions or thin permit shall be
D deemed revoked, - fU1LDING FEE I= i
LU
CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereleyaffiren that there is a construction land Ing agency for the perform- ELECTRIC FEE
7 Z ance of the work for which this permit is bsud(Sec.Mor,Civ,C.) TOTAL: I ��+
U O lenders Name x PLUMBING FEE 11)
IL F Lendcr'.Addres. . QTY`. MECHANICAL'PERMIT 1 'FEE 1MECHANICAL FEE a
OW l certilythat l haveread this application and statethatthe above information �r�t
1 Iscorrect.I egreelo comply with all city and county ordinances and state law. PERMIT ISSUANCE kL-fY FEES PAID: -
W relating to building construction,and hereby authorize representatives of this _
F Z city to enter u Pon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harMen the City of Cupertino Date Receipt#
V aga Wtliabihtie,}idgnsnts,rostaandexpen.ewhichmayinan a ecr e AIRHANDLINGUNITR010,000CI1M) SUBTOTAL'
;Z.,1d City In cons u on ofthegranti enret. eV/
AIR HANDLING!INR(OVER 10,000CFM) CONSTRUCTION TAX
a turcof Appl fit/Cmra or IAT IT
EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE --- '
'Willtheapplinnt or future building occupant store or handle haeardms HFATINGUMT(TO 100,(10 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Cade,Chapter 9,17,and the
Heath and Safely Code Semon 2537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA
_ Yea No
Will the applicant a�ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESIU) LS$UANCE DATE
whkh emaa
it hardous air contamleants as'deflned by thc.B.y Area Air Emsputz
Iity Management DiaWct7 BOILER-COMP OHP OR 100100 BTU)
Yea �No �U�
have read the Faz. oils materialsrequlrcmenn under Chapter 6.95 of ROILER-COMP(OVFR 100,000 BTU)
the Callfomia Health k SafetyCode,Settlors 755015,25533 and 75534. I
u ndersto n fid that if the building donot eu rcent ly have a tenant,that it Is my NEW RIS!DENTIAL MECH. Y1.FT.
responsibility to not lfy the occupant of the requirements which must be met —
asp{ff��ss�s�FF{{ssFFss�4�
prior to Woo nn of a Certificate of Occupancy. . Y
Owner or authorized agent Data - TOTAL �1 7SSIlEUO
' : vW
OFFICE COPY