21122 (2) APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY k D 2Z
Building Project Ideml(Ical°n IL-0 r'ZZ PERMITNO.
Budding Address: 1. 112 2
@'03q1 a l a >1 r� L o I Q 2
suer asrc:p�� �, � ane:
t-( f 7"--'15I �j-(ZQ'UT CITY OFCUPE ATIO if PER DIVISION ' c) r I—qo
. Co tra or'eNa a: APPLICATION /PERMIT
�� `^ &y4-<h� `--e5 g0� BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROLa
ArcM1ite gin q- I C _5-BGGLk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMIT ISSUANCE
LICENSED CONTRACTOR'S under SDECns of ChON
I hereby
ectionrmthat arm DiW.in3.fth. erprovislansaf Chapter9(commen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Inall7000)of Dlvlslon3o(the Buelnuand ProfeulonsCode,andery
license le in full and c.0, � PANES ��Dy
LIttrCla L�N_ �
Date Conlranor_
ARCHITECTS DECLARATION 701-1000 AMPS
p��puu aO Zp ]understand reyplanshallbeused aspubllcremrds OVERIWOAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
LicensedPro(cmlam 9GNSEI.EC77UCAL ��fl. 2 /y(''Jn
OWNER-BUILDER DECLARATION' SPECIALCIRCUIT/MLSC
T hereby a(Brm that I am exempt from the Conlrad.e.License Law for the
following reason.(SMIon 7031 S,Buelness and Professions Code:Any city or
y 4.. county which exqulresa permit toconstwce,alter,improve,derrolish,or repairgDNP.METQt OR POLE INST.
anystrodumpdortoltsiswance,alsomqutmatheapplimnifwwchpermitto POWER DEVICES
file a signed statement that he is licensed pursuant to the provision of the
0tt Contractori License Law(Chapter9(cammenclng with Semon 7000)of Divi-
SWIMMING POOL ELECTRIC
sio"ofthe Buslnessand Prefomlon Code)orthal he is exempt therefromand VALUATION
y.'S the basis for the alleged exemption. My violation of Bastion 7031.5 by any
0 Rant for permit subjects the applicant to a civil penalty of no marathon OUTLETS-SWITCHES-FIXTURES
I /ifs �•1 t
EE11 fve P K PP Pe ty
five hundred as owner dollars0",
pro NEW RESIDENTIAL ELFf1R SQ.FT. STORIES ' TYPECDNSTRIICTiON
�n
F1 1,as owneroftheproperty,or nT employees in with wages as offered
fo
rompenas?'OK Business and do the Prod the fessions
Code:
reh not Intended or offend for
O does(Sec.apply
to Business and f propelon Code:The or impanols Llcene Law
docs not apply to an owner of propertywho builds or improve thereon,and OCC.GROUP RES,UNITS
whodoeaeuchwork hlmmdorlhrough hlsownemplay"a,provided that such
Improvements are not Intended oroffered forsale.If,however,the building or TOTAL;
Improvement issold within on)earo(completlon,the owner-bullderwiil have TILS
OW-kurden of proving that he did not build or Improve for purpose ofule.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �sOT
contndla controd the project(S..7014,Business acid Professns ioCode:
or. V
The Contractor's License Law dm not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or Improv"thereon, and who contracts far such ptojec - -
a with a TFEE SUMMARY
ct r(s)danmd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
am exempt under Sec. B&P C for this reawn
OUTSIDEFEES
DRAINS FIGO ROOF,& SANITARY Y N
• Owner Date R AREA, RECEIPT#
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y— N
01 hereby orO m that I have• l rt me of consent to pythsurc,or RECEPT M
3800,mhtfab of Worken'Comperwtlonlnurance oracertlfled copythemof(Sec. GAS F.A.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
3500,fab CJ
1'oliry p RECEIPT M
C00�++++any GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
I ICertlfled ropy is hereby(ume efty GREASE/WDU L r w NCHECK PEE
LKJ Candied copy is(fled with the city Inspenlan dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TIAL' Lea CD
COMPENSATION INSURANCE SEWE3rj" Date
RCCC1 171 ,1`+�
(This.anionneednothecompldedlfthepermit isforanehundreddollare WATE
TER W/VENT/ELECTRRGYFEE Y N
I nnifythat in the performance ofthe work fmwhlch this permit Is blued,1 shall not employ any person In any mannersem to became subject totheWATIEh1/
Workeri Compensation Lews of California.Date AID
z Z Applicant NEWRESIDENTTALPLMIL SQFf. Date Recei til
Z O ,NOTICE TO APPLICANT:Ifafter making this Certificate of Exemption,you
Hshould become subject to the Wm1oma Compenat ton provision of the Labor TOTAL:
CC
N Code,you most forthwith comply with such provision orthis permit a hall be B 1 E
� deemed revoked.
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE Iherefthbyaf/lrrnthat there is a contraction lending agency for the perform TOTAL I ELECTRIC FEE
Z ance oe work for which this permit is Issued(Sm 3097,CIv.C.) I ^n
V 2 Landers Name t PLUMBING FEE L4l
LL !- Lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL PEE Z,
O W Icedi(ythatl have read this applialbnand statethat the abovelnfomWirm
is comed.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE �LaW FEES PAID:'
} 1 relating to building construction,ami hereby authorize representation of this -
F2 city to enter u Pon the abo, cmendoned properly for Inspection purposes. ALTERORADDTOMECH.
- (We)agree to my,IndemN an d kee armi the City of Cupertino Date ReceiptM
;34
lealhoblllties Brenta, sand me ch may In anyway due AIRHANDLINGUNITCTOELMOCFM) SUBTOTAL• - s
Id nron ceof t this pe
O AIR HANDLING UNIT 10,000CFM) CONSTRUCTION TAX
nturc
__of
cit/Contractor to IXFIALJST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO E �4
Wilot appliantorfuturebuildingoccupantstoreorhandlehazardous HEATING UNIT(TO 100,000BTU) 1 S'Ie{ayQ
nuterialas defined by the Cupertino Munldpal Code Chapter9.II,and the Date Recei t#
hlnith and Maty Code Sedlon 75537(a)? HEATING UNIT(OVER 10,000 BTU)
Y. TOTAL:
no
illthe appllcanl or lNure building occupant use equipment or If evices VENTILATION EAN(SINGLE RESID) ISSUANCE DATE
which emit haurd....Ir contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMP 0HPOR 100,000 RTU)
(-1 Yn No
ave read the ous nuteciab requirements under Chapter 6.95 of BOILER-00\41I(OVER 100,0008TU) y
the Callforela Health&Safety Code,Section 25505,75533 and 25534.1 ���
u aderstacid that it the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECIi. SQFT. II
responlbilityto not lfy the occupant of the requirements which moat be mel
prior to issuance of a Certificate of Occvpa my. grss
4 ��s�Rk It)a��� j�a� tA�/171
Owner or authorlred agent Data - NOTAL. ISSUED BY: C� �`a•Ct1'
_ l
OFFICE COPY