21110 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 407-10
Building Project Identification u PFRMITNO.
Building Address: L+G3 21110
03s Vola U � 10
anon axes; on<: A
H�}RA' ,J t G--Q.Ql1P CITY OF CUPERTINO-BUILDING DIVISION I�
BUI
cont �N [- OhbaayaSh; ;� i` I APPLICATION /PERMIT -
m�dg�t � pee J LDINGELECTRIGLPLIJMBINC-MLCIIAMCAL CATEGORY CONTROL N
A R LN G Ne. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERhETI55UANCE F1 00
LDia
LICENSED CONTRQDECLARATION t?]S FfN�®W 1t
..
LL
LE
I hereby
affirm that lam Bcnsel under prwLof Cha plot 9 APPLIANCES-RESIDENTIAL JOB DESCRIPTION
IngwthSectIon70W)olDivelon3ofthe8pinand fefMion.Code,andmy
Il xInfuW ✓ PANES
ceCM
t.ei: ie.I
onnttorUP TO 20DAK?.S
ARCHITECTS DECLARATION 201-IODOAMN
^WWW0 O I understand my phru shall be used m public reaanlc , OVER 1000 AMPS �.FI'.FLOOR AREA S/SQ.FT.'
�2rvil y w�j Llmnaed Profeselmul SIGNS ELECTRICAL
R c6 g OWNER-BUILDER DECLARATION SPECIALCIRCU1T/NLSC � r
z Gd& I herebyafBrenthat lam exempt frmetthe Contradoe.Llnnse iaw for the ZZ b
qqqq ( ntyngichrvgfSe aMrnil$Buslnemand Pimp a e=lCode: n cityr ���
founting re on.(Seaion 703tlo roatact,adProfpmvgdemall A orrea t TEMP.METER OR POLE]NST.
14 a anystructure priorlo Its bsuance,alsorequlres theapplicanl forsuch permit to POWER gDEVICES
V' file a signed statement that he Is licensed pursuant to the providers of the
Ow Cmd.der's License Law(Chapter 9(mmnnncing with Section 7000)of DWI-
�0 xion3 oftheBuslnessand PmfesalomCode)orthat he is exempt therefromVALUATIONand SWIMMING POOL ELECTRIC e
the basis(or the alleged exemption. Any violation of Section 70315 by any
pr5'1 applicant for a permit subjects the applicant to a civil penalty of net more than OUTLETrsSWITGHES-FIXTURES
$
five hundred asrowneof thepe. ts NEW RESIDENTIAL ELECTR SQ.FL 5701RIFS ( L TYPE CONSTRUCTION
7�r ❑I,asewar ofothe weerty,or my employ u,noes t
withwagesr offereir d
fo
mmpewtion,wllldothe work endthestacturc lsnoHntended or of(emd for 0
pp O cele(Sec.7094,Business and Professions Code:The Contractor's License Law
[;75$ does not apply to an owner of property who bo lids or improves l hereon,and OCC.GROUIa RES.UNITS
❑❑ whodoee such work hlnseBorthrough ldsownemployess,provided that such
improvemenbammiH tendedorofferedferule.If,however,thebudldingor TOTAL-
Improvement O
lasold within omyearofcomplMion,the ownenbu0derwBl have
tF,,Iurdenofpmving that he did not build or Improve for purpose ofuleJ. QTY. PLUMBING PERMIT FEE FLOODZDNE APN
L„J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '2s
..trade.to coatad the project(Sec.7044,goal..and Prnfessoa lCode:
The Commences License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wild.or Improves thereon, and who contracts for such ptoktte with a FEE SUMMARY
cqp{�+dor(,)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
•
OUTSI Dr.FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Date RECQI'I'N
WOR KMAN COMPENSATION DECORATION FDnURES-PER TNM SCHOOL TAX Y N
QI hereby af(bm that I t•certificate of consent to op therm,or RFGEIPT N
certWcate bC.) ricers Compevatlonlaurancemecertlfled copy thereof(gee GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Polis Lab C.I
Polity N RBCFR"f M
C
ray CAS V ) BUILDING DIVISION FEES
nCertified copy Is hereby furnished. CRF PLANCHECK FEE
Certlfled copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' G as E PAID pry.
COMPENSATION INSURANCE BEWF.R-C��STORM G.2lXIFT. Date RCOCI [N aS.!
(fhlssedionneed net becoreplcted ifthe permit bforomhundred dollars -RNRrG a
($100)orless3 WATER HEATER W/VENT/ELCCTR NERGYFEE Y N
Icertify that In the performance ofthe,work forwhich this permit b lamed, — . —
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING Wmkcn'Compenutlon laws of Glifomh.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. Dale Recei [#
Z O NOTIGETD become
ttothe orkerafte, Comping rCilen provisions
oft the
c"Q'FT•
CC Code,you
ubjedmthe Workers'Comproviers orthioarmit s Lab or TOTAL:
LU W Code, coked.forthwith comply with each provlsloa or this permit shall be N G
> deemed revoked.
(L p CONSTRUCTION LENDING AGENCY SEISMIC FEE
BUIL
d CONSTRUCTION I herebyaffirmn that there is a roatmetlon lend ingagerny for the perform ELECTRIC FEE
D Z arm ofthework for which this permit la laeued(Sec.3097,CW.C.) .TOTAL: Q
U O Krises Name PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
LL L) Lenders Address tionMECHANICAL FEE
A77t T6
O W ]reed,Idg hocomplywith aave mad this licetlondcounand tymeRnarcesein(orts Is"
1 mlatlect.Iagreeto complywlth alndhembyathooseeprcesand gets PERMIT ISSUANCE Z_� FEES PAID:
�. W relatl to enter
rupont roatactendlon hereby authorize repreaenpurpos o(thb
I- Z city(We)
agree
to the sieve-men/toned property for Wpe cit purposes. ALT�20R ADD TO MECH. Date Recel HI
- (We)agree s,ave emnity a d keep h Mesa the Clty y Cupertino P
against lbbWt cab,cost dexpb sable mayln any ways AIR HANDLING UNIT DO CFM) SUBTOTAL' s
agalat mm�sequen (tM ntin of p<tmlt.
et
Q AIR HANDLING UNIT(OVER 10,=CFM) CONSTRUCTION TAX
gnatureofA ant Contractora EXHAUSTI[OOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC SUR .s
Wllllheappliant orfuture building occupant store or handle haurdous HFATINGUNIT(T0100,000BTU) Date RBCeI tR , as�
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 1W000 BTU) TOTAL:
T1 Yes M No
Ill the appllunt orfuNre bulldingoccvpant use equipment ardevkcs VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous airmntamiantsas defined bythe Bay Area Air _ 9O.
• Quality Management District? BOILER-COMP OF B'OR 100,000 BTU)4 Yes No
haveread the bazar out materials ecims 25re5,2553cand 2554. 1 of RORER-COMP(OVEIt 100,000 OTU) i JAM NA''991
theCaliforniaHealth&Safety Coes not
have.land,that. ] 49 a7 Us71y0
understand that lfth< Ilding does not mrrcntly have alenani that llbmy NEW RESIDENTIAL MECH. SQ.17. i
rsspoalbllity to he amp of them men which nasi be rrnt
prier to a Certlflcat Oav /V�s!he 22 Fie-a�-Si-q
or aur' art a cat Date V F— r'1).-/`s"�'�
TOTAL: O ISSUED OY:
OFFICE COPY