21112 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 04 O Z
Building Project Identification OY a- LFII Q PERMIT NO.
Building Address: l 11 Fr /dal rl al n
633S` Vo onC2sv � GI I IG
ners ams: e
A
RW__rP'NI GOOyp CITY OF CUPERTINO�BUILDING DIVISION
Co
^trot oor'.Nay. ( ( m e' APPLICATION /PERMIT C^� 6
• LI'IS- O/1 a&h, BUILDING-M TRICALPLUMBING-MECHANICAL CATEGORY CONTROL
Archr/& n er. ! Lk.No:
„ L L M C — �� 66 BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address: PERM9TISSUANCE '?c Cb ® ® mal
LICENSED CONTRACTOR'S DECLARATION LTJ
lzo
I hereby
eRtrmthat) lcrnsed C9c- MPLIANCESRESIDENI7AL
LP
lnnioDivision 3ofthe Business
and ProfessionsCode,and my �JOB LSEJM
ON
license is In(uWeVeneandeffect. '
PANELS S
LIm Cs ICM ✓/ /
Date CLonlranor ��(/ '
ARCHITECTS DECLARATION 201-1000 AMPS
p�p�uu O I understand my plaro shall be used as public recons. OVER 1000 AMPS SQ.FF.FLOOR AREA E/SQ.FT.
6i
Cu,
Licensed Professional SIGNSELECTRICAL '2„�J�
, LI�fYyI ,
<<�¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC L+((. 43
z p.,[�'�
f Ihercbyasom (Seatlam7031.5,pt(roi essand Professions
Code:h,wonToy or
ontywhlchequimsapemittocoatud,alterlmpw.,de=lishrreair
TEMP.METERORPOLE)NST.
any structure polar to Its Issuance,also requires the applicant fin such permit to
POWER DEVICES
O floe a signed statement that he Is licensed pursuant to the tjor 7Eoru of the
3q�+ Cantrsnore License hdProf iomCoer 9 m)orthagwlthmmpthomfmfDivi- SWIMMING POOL ELECTRIC VALUATION
ebn3a(lhe Buatnesaend ProfmlmnsCode)orthat hesexemptthere(romand
C the basis for the alleged exemption. Any violation of Section 7041.5 by any OUTLETSSWITCHIRSFIXTURES ` y( (� DG �l �—
$� applicant for a permibubjem the applicant to a civil penalty of not room than V 1.
five hundred dollars($500).
❑L as owner of the property,or my employeeswith wages as their sole NEW RESIDENTIAL ELECTR .FI. SIOWES TYPECONSIRUCTION
compensation,will d o the work,and the structure is not Intended or offered for
O cele(Sec,7064,Business and Prof extona Code:The Contractor's License Law
$ does nm apply to an owner of property who builds or Improve,thereon,and EEE OCC.GROUT' RES.UNITS
who doeaauch work himself or through hisown employes,provided that such
Improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
T-1 05-
Improvementissuid wilhinoneycarofewnpinbrytheowner-bullderwlll have
IFLJ;ruden ofpmving that he did not bund or improve for put"ofsale.). QTY. PLUMBING PERMIT FEE FLOOD—ZONE APN
Lf L as owner of the property,am exclusively contracting with Harmed PERMIT ISSUANCE '^-a
contracfom to censtrun the project(Sec.7044,Business and Professions Code: t 05
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and whoec contracts for such p(ojects with a FEE SUMMARY
c'yV.dor(s)licensed pursuant to the Commences License Law, BACK FIAWPROTFGT.DEVICE
LJ I am exempt under SB&P C for this maxen
•
OUTSIDE
Owner Data DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N- N
WORKMAN COMPENSATION DECLARATION RECEIVE
FD(IURFS PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a l n me of consent to pytheure,ora RECEB'T M
rerttficat C.Workers'Compensattonlnsuranceaamnlfsd ropythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK PER Y N
3BOQ Lb C.)
Paltry N GAS FA.SYSTEM-OVER 4(RA) RING DI N
Com ray BUILDING DI VISION Fr.ES
�Ccrtllled copy Is,hereby furnished.
CR4r/I?jDj*44.4j,Iffft R PLANCHECK FEE
Certified copy s filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GR PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA. Date Recei t# !'StC�
(I'hbuelon need not be compined)(the permit Is forone hundred dollars10
(5100)or rtifyt.) WATER ELF-CTR ENERGYFEE Y N
I shall not employ any person In any manner ro a to become subject to the WATER SYSTEM/TREATING
Workers Compenwtlon hove of California.nla.Date PAID
Applicant
O Z Alicant NEW RESIDENTIAL PLMB. :LIFT. Date Reeei tN
Z Q NOTICETOAPPLICANT.If,after making this Certificate of Exemption,you
Fshould become subject to the Workera Compeaatlon provisions of the Labor TOTAL:
� y Code,yours.tfonhwithcomplywlthsuchprovslonsorlhispermitshalibe tQ
j deemed revoked. -BUILDING a G CONSTRUCTION LENDING AGENCY SEISMIC FEE Zt
Ihembyat0rm that there isaconstmctlon lendingagency forthe perform- TOTAL: caa[lw•a ELECTRIC FEE
D Z ance ofthe work forwhichthis permit is Issued(Sec.3097,Civ.C.) Ck t6D O
U O Lcode,s Na rc PLUMBING FEE
LL F Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEEp
O W Icerlfythatl have read thsappIlestionaal statelhattheabovelnformmlon 1
is mann.Iagreetocomplywithallcityand countyrrdlnanceaand nate law. PERMITISS'UANCE la eyj FEES FnID:
M relating to building construction,and hereby authorize miumaenstives ofths
1- to ntytuenterupon the above-mentioned property for Inspection purposes. ALTERORADDTO MECH.
?
(We) sort to ssv Indemnl(y and keep har ca the Clty of Cupenlno Date Rxel ted
V against lsbllhies,' gmens,co cid expo hl maymanywaya A1RFEANDLING UMT(TOt0,000CIM) SUBTOTAL: .
against i nconaeque fthe o rs permit.
NR HANDLING UNIT(OVER I B4ODO CFM) CONSTRUCTION TAX
SISIBIEurrofAp ran onto a EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7A RDOUS MATER IALS DI SC SU 1
Will the applies cit orfuture building occupant stare or hand to hazardous HEATING UNIT(TO 100,000 BTU) ry�3 L6
material as dented by the Cupertino Municipal Code,Chapter 9.12 and the _ Date Recel tk
HeAth and Safety Code�-Srection 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. 1I No
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit Hazardous air contaminants as dented by the Bay Area Air
•
Quality Management District? BOILER-COMP DEE'OR 100,000 BTU) U
4 Ye. I-I No
havo readlheh. ous ma teriasrequlmmensunderChapler6.95of B0ILER-COMP(OVI7t100,000B'H3) -^
the California Health&Safety Code,Sections 75505,25533 and 75534.1 /pd R1I{� l II
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.I7. �N19
responsibility to notify the occupant of/he rectum menta which at be met
proutossuanmda CenificateofOttupsnry. 02;0 •,
�T-
s
Owner or authorized agent Date TOTAL Q ISSUED BY: �7
OFFICE COPY