21107 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Or
Building Proeldemiflatian
OPFRh11T NO,
B°�WRAd 3 g S VoT- 7 e �� 21107
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me: rXnATE
CITY OF CUPERTINO-BUILDING DIVISION
C `0
C. ct«e am: Na APPLICATION / PERMIT l
kPI;-1)JbAVa5k '35 BIIIIlNNGELECTRICALPLIMBINGMFGHANICAL CATEGORY CONTROL Y
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFOIC
Add. PERAffTI55UANCE ® ® Y LQ
LICENSED CONTRAROR'SDECLARATION Is
alfinnthatla AM.3 ith under pmvle.dP fO ..r9(mmmmc APPllANCFSRESIDENITAL JOB N
ing ose is ectbn7000)ofd rffd i3olthe Bsu�y�Nr''i�w�Ss��an'd�Plr/c1�WonaCadgand
have V In fin d dfetl-o CI.A PANELS s�w L
Lice Ch - o an Lie a
Date Contractor
ARCHITECM DE RATION -1 AMPS
q
Oce, IundnwM myphroehailbe.sedaspublicrta
od, OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
q��++WW O
k LyL E Clamed Professional SIGNS ELDCrMC L
<6 OWNER-BUILDER DECLARATION gPFGGLCRtCNT/MISC
Z �l Iherebyaf0mn that lam exempt from the Contractor's Llmro Law for the
O(,�F❑ folli rtaeon.(Socdon 7(315,Busher and lhofealov Code:My city or TFMP.METPR OR POLE INST.
Kcounty which require,permit to covtuct,alter,Impmve,demolish,or repair
q any structure prior to Its bsuawe,alae requ urs the applicant for suds permit to POWER DEVICES
Fi Ne a signed statement that he Is licensed pursuant to ticro
pvbbns of the
OwI• Contnnor's Ltceve law(Chapter9(mmmencing with S [om7000)ofDM.
30;.7} don3ofthe Budneaand Professlov Co e)ortheheleexempttherefmmaM SWUAMING POOL IT ECIRIC VALUATIObf
Sar' the back for the alleged exemption. Any violation of B Too 70315 by anyO
sppliant fora permit subjectsthe appBcant to•tl l penalty of not more than OUILE'ISSWITCHESFIXURES l� f�JOI S
F Y fi undreddameagora.
A I,asowvrofthepmperty,ormyempbymw hwagesstheirwle NEW RESIDENTIAL ELECTR SQUrf. STORIES TYPECONSIRUC1'ION
mmpevatlan,will do the work and the structure Is ect Intended or offered for O
Dale(sec 701,, mains and Professions Code:The Contractors License law
$ does not apply to an owner of property who builds or imprwn thereon,and
cs^ who doesueh work himself or through his own employees,pmWedthat such OCC.GROUP RES UNITS
improvements art not Intended oroffered fade.If,however,the building or TOTAL.:
bnprovemeN is dal withinovyurofcmnpletbn,theowner-bullderwlB have
tla,IIunlen of pmving that he did rot wild or Improve for purpose orale.). QTY. PLUMBING PERMIT FEE
Lj L a,owner of the Property,am exchaNely contracting with flared FLOOD IDNE APN
w
mntractons to mvtrue the projed(Sm 7014,Businessand Pmfeabv Code: PERMIT ISSUANCE
The Contractor's Lace.Law don not apply to an owner of property who
Wild.or Improver thereon, and sub contracts for suds p,*rs with• ALTER-DRAW k VENT-WATER(Fl)
Cgnlf+deme)Banaed paranant m the Contract«s Llceiae Law. BAac FInw PROTfGT.DLv1cE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reawnQ1JTRTnF FF FR
OwnerDate DRAINS FIAOK ROOF,AREA,GOND. SANTTARY Y_ N_
® WORKMAN COMPENSATION DEC1ARATIOP4
❑1 hereby affirm that I have a certlBate of cement to self-Wort,or s FD(TURES�PER TRAP SCHOOL TAX Y_ N_
cerUfiram of Workm'Ce mpevNm I...as centi(led copy thereof(Sec. RECEIPT a
3800,Lab C.) GAS F.A.SYSTEM-1 INC4 OUTLETS PARKFEE Y_ N_
Policy REC=a
/ CAS FA.SYSTEM-0VER4(FA)
C
Cograylfled BUILDING DIVISION FEES
cmertcopy b hereby fumbhM. CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CertNed copy is filed with the city Ivpectbn division.
CERTIRCATEOPIXFMPTIONFROMWORKERS' GREASE TRAP PAID n
COMPENSATIONINSURANCE
permitg}yER,SANrrARY-SIURM EA pig;T , Date R t(b
(This sectionrami nes be completedpermit ov hundml dollars
($100)alessa WATER HEATIIt W/VFM/EI.ECIR ENERGY FEE Y N
I certify that In the pedomance of thework forwhich this permit is Issued,
I shall nm employ any person In any manner w a to become subject to the WATERSYSMA/TREATINIG
worker Compevatloo lawso(Gllfmnla.Date PAID
O Z Applicant NEW RESIDFNDAL FLMB. SQ.FI'. Dale Recei t#
Z O NOUCETO APPLICANT;B,after maldng this Certiflateof Exemption,you
should become,ubjed tithe Worker:Compersatbn provision,o(the Labor AIL
~ N Cade,you mart forthwith comply with such provisions orchis permit shall be
W ] deemed revoked. ^ 1
CONSTRUCTION LENDING AGENCY SEISMIC FEE a
a IhembyafRrm thatthemis mvvudionlendingagencyfortheper(ono- ELECTRIC FEE
Z once of the wurkfor whlch this,=b isued(Sec.3097,CN.C) TOTAL: 0 6-7-16
(� O Lenders Name PLUMBING FEE 0
LL r Lender,Add. CITY. MECHANICAL PERMIT FEE MECHANICALQQ
O W I nertifythat l have read thbappll tion and statethat theabeve Ind omatiai
bcormG.Iagrte to cmnply wlthaB cttyaM county ordWnm and date lewa PERMIT ISSUANCE �L Q1 FEES PAID:
} N relatingtowlldingmnatuctlm,and herebyauthodmrepreamtativnofth6
F Z ''ltY to entuupon the abosc�ntbvd pmperty(or Wpectio punposea. ALTERORADDTOMETI. Date Revel t#
_ (We),gree to ave,i demN an d keep harmless the City of Cupertino
agalutRabWt dgmeNs, andc soh mayin.ywayamae AIR HANDLING UNIT(7010,010 CFM) SUBTOTAL:
agat I In of tinpemrt.
7) Ila
AIR HANDLING uNTr(OVERloo)ocFtif) CONSTRUCTION TAX
gnavrtof B t/Cantr,ctor to EXHASFiTHOODMIDLCT) NTA
CONSTRUCTIOX PAI0. 'Za
HAl RDOUS MATER IA LS F'C10SUR 1
Wel theappllart or future wilding o¢opant scone or wMle hawdmas HEATING UMT(10100,(00 BTU)
Date Receipt
material a as defined by udted coon I!M Mudtlpal Code,Chapter 9.17,and the
fkalty. Safety Cadr Section 2S53i(a)7 I-TATINC UNIT(OVER I(1D,(glO
❑Ye �No
WOemt lb p.nl uor tum wilding nants.mvpantuu eine Bay vvdevim VENIIIATgNFAN(SINGLE RESID) C1${�.[Ugfx]LFap�
whkh eMt gerrent aboxntaMnu Nsas definrd by the Bay Arta Air
Quality Alavgement Db1rk17 BORER-COMP OHPGR 100,fXDBM 6aV
Ya ❑No
Uvccadleeh m
addab rtqulrtunderChapternrcoft
BO3COMP(OVER 100,00)BTN
the Hn &Safet Coda Sections;25505,
nd25534.
1
understand that ifthebuDdingdotcntlyhveatenant,that itbmy NEW RESIDENTIAL LE(i. BQFf
resperoibilftryto ndifytheapmel themtubennent,which nrasib
priorto issuance
M�✓l�,il
hTRygy.,_"a1"l
of•CertlOote of Occupancy, a
Owner or authonbed agent Date ISSUEDBY�'
OTAL O
OFFICE COPY
1
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