21105 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 07 -,S --
Building Project Identification
BX 0 '4,a1- Vo I d 0 s R
PERMIT NO.
21105
wnere ana: one:
_d-8 NZ &Raulp
CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING.ELECTRICAI.PLUMBING-MECHAMCAL
rate 'eN ma•Lk. Na:
N a G � o
CATEGORY
CONTROL X
Archil /Engi k o
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
® S51
I.CI
Address:
PERMTISSUANCE Q7
LICENSED CONTRACTOR'S DECLARATION
Thereby affirmlhallamikrnsed under provisions ofChapmr 9 (aimmene.
ingwlth5eelan7DOO)of DiW3ion3ofthe Busineaeand Pfad.r.Cocleandmy
license lslnft o eandeffect. 6G/
Lima CI Lt.Y bb..5
AI'PI.IANCESRESIDENML
)OB DESCRIPTION
�cD'1'�
T-' K.1
PANES
Date Contractor P, V
UP TO 200 AMPS
101-1000AMPS
ARCHITECT'S CLARATION
fundemtandmypiamahagbeuwdwpub0cremrds.
OVERIODOAMPS
SQ. IT. FLOOR AREA
$/SQ.FT.
SIGNSELECTRICAL
Llcemed Professional
''2'383
OWNER -BOLDER DECLARATION
I hereby a(Orm that Iamexempt from the DECLARATION
License Law for the
following motion. (Section 7031S, Business and Pro(eesices Code: Any City Or
munlywhich require a permhtamngruct, alter, improv, demahsh, orrepalr
SPECIALCIRCUIT/MISC
1
a/i/•''
TEMP MITER OR POLE [NST.
any structure prior to its bsuame, also requires the applicant forsuch permit to
file a signed statement that he b licensed pursuant na to the provlsloof the
Contractor's License Law (Chapter 9 (mmmenclog with Section 7000) of Divi-
sion 3 ofthe Bustemsand Piefasslom Code) orthat he is exempt therefecmand
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 7001.5 by any
applicant fora permit subjects the applicant to a civil penalty of net mare than
O[TILEISSWITCIffSF[%'1'URES
/ Q -T
l 71
NEW RESIDENTIAL ELE-CTR SQ.FL
five hundred dollars ($SD9L
❑L as owner of the property, or my employees with wages as their sale
U .G..
STORIES
TYPE CONSTRUCTION
compensation, wllldolhe work, and the structure ism Intended or offered for
sale (Sec. an and Code: The Law
to ow
doseoe nor apply roanawmr o(p rough whoWild.
applyf propertyor improves
emorimproovided eoMand
whodoessuchwork himself arthrwghhisown employees, provided that such
OCC.GROUP
RES. UNITS
Improvements are not intended oroffered tarsale. If, however, thebuilding or
Improvement istalld withinoneyearofcomple0on,the owner-bullderwlll have
tFtR)rudenofproving that he did rat bund or Improve fm purpose ofsak.).
LLff L as owner of the property, am exclusively comeacting with licensed
contractors to construct the project (Sec. 7044, Business and Professions;Professions;Code:
TOTAL:71, SO
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE ,et,e
�-( J
FLOODZONE
APN
The Contractor's License law donet apply to an owner m property who
e
builds or Improve thereon, and who contracts far such pVjects with a
egy(adoKs) Lensed pursuant to the Contractor's Lt... Law.
LI I am exempt under Sec- B k P C for this reason
ALTER -DRAIN 4a VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
ETS
DRAINS FLOOR ROOF, AREA, COND.
17XIURE4 PER TRAP
SANITARY Y N��
RECEIPT M
Owner Date
WORICNAN COMPaTJSATION DECLARATION
❑ hereby affirm that I have a ertlRcale of cammnt to .sure, or
mrtlfkaof Workers'Compenaalloninaunna oracertified ropypy ththereof (See.
3300, Labb Cd
SCHOOLTAX Y_ N_
RECEIPT 0
GAS PA. SYSTEM[ INC.4 OUTLSTS
PARK FEE Y N
Poll, If
M
GAS EA. SYSTPM-OVER 4 (EA)
Company
DINRECEIPT
BUILDING DIVISION FOES
11 Certified copy is herebyfurnished.ilm cid.
IYJ•Cenl(Ied mpybtllea with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TNssectionneed not becorepleted ifthepermit bforom hundred dollars
GREASE/ INDUSIRL WASTE INTERCEPTOR
EGK FEE
(CJ
PAID
Date Receipt
GREASETRN'
- SEWER -SANITARY -STORM EA. 200n.
($100)orlcnd
I rtify that In the performance of the work forwhlch this permit la ised,
ca su
1 shall am employ any person In any manner an a to became subject to the
Worland Compensation Laws of Cal fomla. Date
WAITS HEATER W/VENT/ELI:CTR
E•NERCY FEE Y N
PAID
WATER SYSTEM/TREATING
ApplicaNOTICE
NOTICE ca APPLICANT: a cher making late Certificate is Exemption, you
Code, becomesubject to the Workers' Comp rovisinprovblomofthe Lab or
Cade, you moat forthwith comply with each provisions a'tla's permit shall6e
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB.__SQ.Ff.
AL;
13UIL ING FEE 00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby affirm that them b a construction lending agency for the perfare,
once of the work for which this permit ls Issued (Sec. 3097, Civ. C.)
TOTAL:
!
ELECTRIC FE a
leadefs Name
Lender's Address
I certltythal l haveread thbapplicebov
tlonand statethattheae Informed.
Ismngct.I agree locomply with all city and county ordlnanresand gate laws
PLUMBING FEE _
MECHANICAL '
QTY. ECHANICAL PERM[ FEE
�T ,�rrys�e�
IT ISSUANCE fl c -CJ
FEES PAID:
relating to bullding mnatmctlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property fm Inspection pu �paee�
(We) agree m cave, Indemn an d keep harmiess the City of Cupedlno
ALTER OR ADD TO MECH.
(`p
Date Recei t# a�9
_
SUBTOTAL:
against llabllfflc rant gsand ex seswhkhmaylnanywayaccru
.gaunt Id nruns raceof it. la permit.
AIR HANDLING UNIT10,000
AIRFUNDLIN ]ofpD
CONSTRUCTION TAX
D(HAUS'TH I1CT) /'
CONSTRUCTI
mtum.f cant/Con actor
-SIgO
HATARUOUS MATERIALS DISC SD
-
HEA C
1 , B >
-
Wlllt e0440
applicant or future building occupant store or handl aaardous
materbl act de(imtl by the Cupertino Municipal Code,Chapler 9 2'and the
Date Recei t# a
T(DY 1 BTI)
TO L:
IicallhandSafety Code Section 25531G)7
❑ Yes No
Will the eppllmnl or tore building part use equipment devices
which cont hacardous air mourmoontsas defined by the Bay Arca r
VfN'DLAI' N(SI ERESIU)
aIrjraUAA]G
Afi .] /•�
BOILER -COM OR100,0ffl 11 )
Quality Management District?
Y. ❑ No
have read the havNno matertab requlremenb under Chapter 6,950
^
R 1 1991
BOILER -COMP (OVER 100,00 RTU)
the California Health k Safety Code, Sections 25505, 25533 and 15534. 1
NEW RESIDENTIAL MECH. SQ.FT
understand that if the building does not currently have a tenant, Ihal Ills my
responsibility to notify the occupant of the requirements which must be rear
prior to Issuance of a Certificate of Occupancy.
p ( nnn^ -•-'�
4�1sM.
sit so
y
ISSUED 6Y: ��s^'�lw
Owner or authorized agent Dale
-
L 7175--A
TOTAL,
OFFICE COPY