21397 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
Building Address: 21397
ko%23 LJIL<IoIJ5'oAl
ante:
I inS_t L G_(2FJ13 CITY OF CUPERTINO-BUILDING DIVISION
• Conrad.•,NNamnse:; /Lie.No: APPLICATION / PERMIT
l nMfy,4L ( S 'SZ�N �ZC7��17 BUILDING-ELECTRICALPLUMBING-MECIIAMCAL CATEGORY CONTROL#
Architect/Engineer. Lk.No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Address: PE1MITIS6UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaftirmthat l am licensed under provisions of Chapter9(rommenc APPLIANCES-RESIDENTIAL ]OB DISC RETION
Ingwith Sectton7000)o(Divlslon3ofthc Busleessand ProtesslonsC-ode,and my
license is In fuRJor¢and effect. PANELS #� `�� �
License Ckss C:'L Lie Y t V�(�'•'�W/p+J
Dale 0 Centnctor E S �1'3
ARCHITECI'S DECLARATION - 201-IMO AMPS a17't•t�
re02 I understand my plana shall be used as Public records OVER IODO AMPS SQ.FF.FLOOR AREA $/SQ.Fr.
CO
(0 Licensed Professional SIGNSELECTRICAL e
�Q OWNER-BUILDER DECLARATION SPECIAL CIItCUIT/ML9C
I hereby affirm that am exempt from the Contractors License Law for the
pp following reame.(Section7031S,Business and Professions Code:Any city or
O Z TEMP.METER OR POLE IN
Fg
county which requires apermhro contrequirsthetruct,alte� aprovgdfrsuch,orrepair such mitto
any structurepaler teits hat heIssuance,is also Homseulrcslhettot het rovidrsof to POWER DEVICES
0.S itis a signed•atemem that M k Bcensed pursuant to the providers of the
O7 l� Contractor'sLicense Law(Chapter9(commencing with Section 7000)of Divi- SWA4MINGPOOLEL C
sion3oftheBusine,sand Profeeelmu Cede)erthathekemmptlhemfmmand VALUATION
�'�p5+ a.•]] the bask for the alleged exemption. Any violation of Section 7031.5 by any OUTLET54WITCHESFI
EppBcant for a permit subkctn the applicant to a civil penalty of net more than
ve hundreddollanheproperty,
le NEW RESRZENTIAL EL STORIES TYPECONSIRUCTION
$ �n ❑enaoon,Z21 othe work,andthe
my employees inwith wded or offeredir fo
mm(Sec.700ABusiess awork,aessio structureisnet Intended orofferedfor
O sale(Sec.70M,Business end Professloru Code:The Contractofs Llueu law
S$ does not apply to an owner ofproperty who builds or Improves thereon,and OCC.GROUP RFS.UNITS
who doesmchworkhlmeellorthrough hisownemployees,provided thatwch
Inprovemenk are not intended prof(end fmole.I/,however,thebulldingm %J T L;
Improvement kmld withinoneyearolcomplObgtheewner-huaderwlll have
tla) rden of proving that he did no[bulld arlmprove for pompom of oak.). QTY. PLU> ING IWMI' FEE FLOOD ZONE APN
u 4 ae owner of the property,am exclusively contracting with..... d PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professioru Code:
The Contractors License Law does net apply t......r of property who
beads or Improve,thence,and who contra !or such ptojem with a ALTER-DRAIN&VENT-WATER(EA)
�IEanor(A Rcensed pursuant to the,Centnctols Linnse Law. gAQX(FPpW pROTFLT.DEVICE FEE SUMMARY
LJ I em exempt under Sea' 3& P C for this reason FEES
DRAINS FLOOR ROOF,ARFAODND. SANITARY Y_ N_
Owner Data RECE7I'r X
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
E31 hereby affirm that I have a certificate of concent m oey rre,ora RECEIPT N
mrttftoiao(Wo.k.r:Comperwttmlruunna ova mrtlfkd copy thethereo(l5ec.
3800,Lab C.) GAS EA.SYSTEM-11NC.4 OUTLETS PARR FEE Y N_
RECE
Poli X GAS EA.SYSTEM-OVER DING DTIV
' 717 Is
Com any BUILUINC DI VISION FEES
❑p Certified copy k hereby filed
the city GREASE/INDUFML WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy k pled with the city Inspection divldm.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GRE'A'SE TRAP PAID
COMPENSATION INSURANCE
(rhlssection need not be completed lithe permit k for one hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Reeei 111
($10(a
Orless.)
1 orI .at N m
the perforanceotthe work forwhkh this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I shall not employ any person N any manner as u to became subject to the WATDt SYSIEMyTREATING
Workeri Compensation Laws of California.Date PAID
z Z Applicant NEWRESIDENTIALPXMIL_SQ.FL Date Rewi till
Z O NOTICE TO APPLICANT:](,after rnaking/hie Certlllote of laemplian,you
(` should be..subject to the Workers'Compematlon pmvklon otthe Labor TOTAL:
N Cade,you must orthwith comply withsuch provisions or this permit shall be LD
W > deemed revoked.
a c
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a cmutroctlon lending agency for the perform ELECTRIC FEE
Z ante otthe work for which this permit k issued(&c.3097,CIv.C.) TOTAL:
V O Lender'•Name PLUMBING FEE
LL I— Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE Z\,e9e
O W IcertHythatl have mad thkapplirailonand stauthAthe above Information
kmrreet.l agree to complywith all city and county ordinances and pate laws PERMIT ISSUANCE GO FEES PAID:
>_ D.0. relating to building mm4uetion,and herebysuthortrre representatives of this
city to enter upon the above-mentioned property for inspection purposes, ALTMORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Dale Reeei tet
:agaeatlkbI lies,pdgme ts,mets end penis whish mayinanywayaorne AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
net iryN once of th •°ling o(lhis parmlL AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
'ignat r or Applicant/Contractor Date MHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE aye
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) (W Date RCCCI tN
material as de0ned by the CuprAi.Mu nidpal Code,Chapter 9.1 2,and the
Health and Safety Code Sectlon25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. No
Will the applicant m uwm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 1$ 1,) ATE
which emit hazardous air contaminants as deft red by the Bay Area Air
alality Management Dlstrict7 BOILER-COMP DH'OR 100,000 BTU) ��� � PB
4 Y. No
have read the haze msmterialsmquimwnkunderChaprter6.95of BOILER-COMP(OVER100,OOD BTU)
the California Health&Safety Code,Seel 25505,25533 and 25534. I
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr �sJ{ss
responsibility to notify the occupant of the requirements which moat be met ) 41 sssa.jj kram
prior to issuance o(a Grtl(kate otl7ccupanry.
Owner or authorized agent Date 1 TOTAL; ISSUED BY:
a CD
OFFICE COPY