21878 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemifiratim - PERMIT NO.
Building Address
-R�� vO &�� 21878
re ams: one:
- CITY OF CUPERTINO-BUILDING DIVISION
. Cbetg eN - Ix.Na APPLICATION / PERMIT ( -
BUILDING-ELECTRICALPLUMBlNG HANICAL CATEGORY CON TROLY
Arehgect/Engines IJc No:
QTy ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrac PERMITISSUANCE - 'Z say ❑ ❑ ❑
LICENSED CONTRam t under SDEC9ARATION
Ihrrtgtion70ffimm lhal Div[sbm3ofthMerprvvblwofChapler9(l,it m APIPI,IANCESRFSDFNIUL JOB DF9C
IngwlthSMbn form and effecn3o/the Burnmard ProfeuloruCad,und my
Ilam h b full form and effect PANELS �I..L
on
LRerse Clas LILY ll-1 �"l l
Date Ctractor � �
ARCHITECTS DECLARATION Nil-1070 AMPS
q�u p Q2 I YrdmuM my plans.hail be used a public records AREA OVFR 1000 AMPS SQ.FP.FLOOR ARS/SQ.Fr.
[j Lkvnsed I'mmestovl SIGNS ELECTRICAL
�«<<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
I hereby afflrmthat I am exempt from the Comractorb Llmnue law for the
7.
following reason.(5ecihs
lus 71315,Buseand Professions Codr.Any city or
17r
02.t-. 7P.MEIR72OR POLE MST.
F� m,nrywhkdm rtqulmapemdt to comtruct,alter,lmprwe,drmnlbh,orrcpalr -
yy anystmu mprbrtoitn me,alwrequhetheappBmat(mwchpe to POWER DEVICES
C file it rSred statement that he h Banned purwant to the provisions,of the
O u, Contr oes Lkrns,Law(Chapter9(co.cing with Section 7000).(DM.
30 eun3 ofthe Bushmessand ProfesbmCodb e)orth,t he exemptthenefromard VALUATION
Es S the bash for the alleged exemption. My Wdation of Sectn SWIMMING NO[.ELECTRIC 70115 by any OU'D.L'ISSSVI.tt3-05FLY'C[JRFS
Oa appBmntforapemdtwbie theappBcanttoadWipenakyafnNmorethan
flv hundred ddhn(9.W. SQ}7, SIOWF9 TYPECONSTRUCTION
'9..' I,as owner of the property,or my employees with wages as their sole NEW RIDDQJIIAL EI.ECTR •-.
compensation,wBldothe wade and the structure is not Intended or offered for wZ
5 O sale/sec 7066,Business and Pro/eelbro Code:The Contractors Umme Law
$$ does not apply to an owner of property who builds or improves theneon.,nd L-k500 I0 q"O
whodmwdiw rkh lfmthrwghhlsmvnemplayee,provbedthatwch - OCC GROUP BE.I1NgIS
Improvements art not Intended or.f(emd for sale.It however,the building or TOTAL
Improvement h sad within one yeirofe rnpletion,the ownenbudder will have
t rden of pmArg that he did not wild or bnpmve fee purpose of sale.). QTY, PLUMBING PERMIT FEE
L as own.of the property,am excluahmly contracting with licensed FLOOD ZONE APN
nlract.to mnmlruet the project(See 70K Buemses and Profesbv Code: PERMIT ISSUANCE
The Comvractor's Lbeme Law don not apply to a,owner of,property who
bu1W,or Improve thereoM1 and who contracts for so& ptoJem with a ALT .DRAM&VEM-WA
c9atractm(U llmn+ed pnraumt to the Commons License Law. BACK FLOW PROTEcr. FEE SUMMARY
Ll l am exempt uMer Sec B &P C for vmn
this ma
DRAINS FLOOR ROOF,A ND. SANITARY Y_ N_ -
• Owncr - Date RFGFR'f
WORK MAN COMPENSATION DECLARATION FIXTURES .TRAP SCI{OOLTAX Y N_
F-11 hereby affirm that have a mNOate or Gwent to veil-Iwrt,m• R��.E
3600,labb CJ S
artlaaof Workan'CampemaBOlmurenm ma mrtB4d copy theneo((Sec. GAFA. -1 INCA 5 PARK FEE Y N
Pdky I
RECF]PII'Y
Com
�Ceray GAS F.A. VER BUILDING DIVISION HES
rtlRed ropy Is hereby mmhhed. GREASE/IM 1 =R PLANCFIECK FEE
❑Certiaed ropy Is(fled with the city ImpMbn dlvWon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
SEWER-SANTEAR RM EA Date Ressi tN
(rhinsMbn need nut bu complRed Bthe pemdt h froom hundred doBaes
(f100)mles.) WATER HEATER W/vF7•rr/ ENERGY FEE Y N
ImrtBy slut Nthe pedormana olthewmkrorwMch WspemJthimsed,
I WB out employ any Ixt.In any manner to as to become subfM to the
WA77R SYSTEM/TREATING
wmkers'compewtlnn lAws or c.lxmnh. Date � PAID
O Z Appb.t NEW RESIDENTIAL.1'IMB• SQ.Ft.. Date Recei tN
Z O NOTICE TO APPLICANT. after
:B, making this Ceduate of Exemption,you
should become subject to the Won'Compensatkbbru m provof the Labor TOTAL:
P
mote
CO Cade,you true forthwith comply with such provblons or this perMl shalltr
deemed revoked.
W CONSTRUCTION LENDING AGENCY — SEISMIC FEE
a I hereby affirm that there h a construction lending agemy for the perfomv ELECTRIC FEE
ana oftheworkforwhlehthhp,,n bbwed LSee3097,CIv.C) TOTAL,
Z
(,) O Pentre:.Name PLUMBING FEE
[- lender.Add. QTY. MECHANICAL PERMIT FEE
0 W I certifythnl hread(hhappiationam
rd state thetheabe lnfornution MECHANICAL FEE
ave
a hcomrt.Iugree to comply wkF sBd[yeed counryardlnanas.na rate owe PERMIT ISSUANCE FEES PAID.
N mining tobuilding construction,and hereby authodre mp.uitWn fthis -
F city to enter upon the above-mentioned m inspection Property for purpmn. ALTERORADDTOMK-J i.
Z.
_ (VJe),gree to sae,BwemBfy and keep harrrdcs the City of Cupedlro k
Date Reeei t
,galost Bt dgmew,cors,nd stns whtehmayln,nyway,mue AIRHANDUNGUNTOOI0,mOCFM) SUBTOTAL:
ago a amt suing"a"Q perms.
AIR HANIXINGIMIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig of Appliant/Contaetm Date IX LST HOOD(W/Dorn CONSTRUCnON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant orfutum building occupant store orhandle-havrdmu HEITMGUNIT(To100,000BTT1) Date RCCeI tN
material as deflned by the Cupertino Municipal Code,Chapter 9.17,and the
Fle.hh and Safety Code Satlan 75537(,)7- HFiATMG UNIT(OVER IM,000 BTU TOTAL:
Fly. No
Will the appliant or�ture building occupant use equipment or devlm VENUTA7TON FAN(SINGLE RE9D) ISSUANCE DATE
which emit harandos air mitandvms m deft red by the Bay Area Air
Iky Ma nagcment DW rM7 BOILER-COMP OHP OR IWX()BTTn
❑
Yn No ICOM[/
shave read the bavndoos eWerlab requirements under Chapter G95 of BOB,ERLCOMP(OVM 100,000 B.T )
the California Health&Safety Cod,Seat ions 75505,25533 and 75536.1
understand that If the building don wcove
t rrently haa tenant,that It is my NEW RESIDENTIAL hIECIL UP
responsibility to notify the omrpant of the requirements which mut be net
prior to law.•. a.Cerulfate ofO p.rcy.
QD
Owner or authorisd agent Date - TOTAL ISSUED BY:
OFFICE COPY I