21668 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project identification L4 v 'y^/ )`9 9/7j� PERMITNO21668
O.. 1 (h'a I(''��
R ing ddrea: / 1 / t/ / � frV IJ 1 V V (�
s onr. jl/�
CITY OF CUPERTINO-BUILDING DIVISION
. C ma ' N APPLICATION / PERMIT (L ( I
G BU DINGE]rS R CALPL h BINGMCCF AN CAl CATEGORY CONTROL
A it / Lle.No
QTY ELECTRICPERMIF FEE BUILDING PERMIT INFO
Address I'FRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECns o(ChON
I thereby.euro that la, Beamed under pmvbl«uoff,, t .dm.dnc AI'PLIANCESRE9DFSJIIAL JOB DFSCRD'TI
Ingw11h5enbn7fl(U)of 'vitlon3dihe Busirsvand f Code,and
Manse b In ellen. / PANELS y al
LleveC Lfcl C
nr
Date CoMnor f%
ARCHITECTS DEC / XI-10DOAMPS
z7. Iurde myplan&.haBbeusedupubhcrc rds OVERIODOAMPS SQ.FT.FLOOR AREA 5/SQ.FF.
CO
t' Lbenaed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Ihereby affirm that Iam e.ampt from the C.etemor'.Lice.Law for the
folbwbig noon.lScMan 7(1715,Bu.lnes and Profesbns Code:My tlty or
O
TE .METER OR POLE INS]'.
r,� muntywhkA requimaperndttomrotrua,atter,improve,demoWh,or repair
anys =mprlortolta Tw e,aborequlretheappbantf«a&pemdtto POWER DEVICES
f file a Mped statement that he b licensed pursuant to the provisions of the
Du,� Cetranor'.Lcense law(Chapter9(comerennng with Section 70(10)of DM- VALUATION�05 don3athe Buslnemand PrdmbnsCode)orItu,heIsexerepttherefrom and SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 70715 by any
HC app0ontforapem mbjecbtheapplkanttoadvlpm Hydn�=mtlun OITILETSSWI7CFT61'1%TURES
fl�g dred dolbus%S00). NEW RESIDENTIAL ELECIR `
7�n Il I,as own&r of the pmperty,or my employee with wage as thetr sob �'�' TYPE CONSTRUCTION
�a< mie(5 a70K B.MreeHew Prow( toes CodeThe C.ndtendedordese,Law
ale(Sec apply Bushesami PrNembro Code:The orimprve,s hemen Taw
.FV�{SQ dmradauchwoanowrerdpmpertywhobuBplyeepravateertort and
whodoe.uN wohhlmeeded orwgh hl.owne.If,hc provided thebuildteuch �� RES.UNITS
improvement are not intendneyear fared plebe.LL howesxr, Elder iling ce TOTAL-
improvement
OTAL
ImproveneM[..old Wllhlr1a11eyearOTCOmpletbri,tFe owner-0uiMerwW have
rden of proving that he did not build or improve fee purpose ofsale.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with Ibenecd FLOOD 9DNE AI'N
contract.to mrelrua Ne pruyl(See 70K Business and Proteslon&Code: PERMIT ISSUANCE
e.� Th Contncm/.License Law does not apply to an owner d property who ALTER-DRAIN VENT-WATER(11-0 builds or Improve Ihereem,and who contracts fee suchpSojema wnh a
ryN(+ctce(.)licensed pursuant to the Contrana/.Lloenr law. FEE SUMMARY
LJ'lam camp under Sec B k P C for this reason BACK FLOW PROTECT'.DEVICE
Owner Due DRAINS F,AREA,COND.FLOOR,ROORESANITARY Y_ N_
WOR KMAN COMPENSATION DECLARATION RECEIPT a
❑I hemby affirm that I have a certificate of consent to.elf-Wurt,or• PIXTl1RES PER TRAP SaTOOL TAX Y_ N_
rvn Hew•OfW 'Com_peru+IonlmuMoe or avert lad ropylhaeo
RECEIPT If
3800,Tab CJ 7 / 1JB� / GAS EA.SYSFEM-1 INC60VD,EfS PARK FEE Y N_
Pol4y RM—
C.
ray EA'SYSFEM'OVER�(FA) BUILDING DIVISION FF
ou
11"'Biedon taf reby tarnish
^� SLasJI Cenln.mpyle rued with he
/HIDDSIRL wASIE INTFxcFrTUR PLANCHPCK FEE
V CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWFR-SANITARYSIORM EA 3IXkT Date Rcacl tit
(ITls s<nbn need rad be completed if the permit b fororc hundred deltan
(n H0or1eis) WATER HEATER W/VFNF/ELECTR ENERGYFEE Y N
I certify that In the performance of the w«k for which this permit 1.hsuM,
I WB not employ any person in any manner so n to become subject to the WATER SYSTGI/TREATING
War)en'Compewtlonlaw.of Callfmmu. Due PAID
V ZMB
Applicant NEWRESIDENIALPI. . 50.67. Date ReCel til
Z U NOTICE TO esub)eAM:R,afterers'Co thio Certelabofons oftbn,ym
�cc N Naild become subkct to the Workers'Comp3nvtbn provision&ofthe Lbor TOTAL
Code,you mat forthwith comply with such provisions mU a permit shall be BUILDING FEE
LU > d«coed revalued.
CONSTRUCTION LENDING AGENCY SEISMIC FZE
d Iherebyaffirm that there b a coretmtllm larding agency for the perform- ELECTRIC FEE
O ance of the work for whkh Nb perodt b tee M&c.309'/,CH.C.) TOTAL
T e d.e.r1la PLUMBING FEE
LL F Lender.Addres. QTY. MECHANICAL PERMIT FEE
LL - MECHANICAL FEE
U omect.laditagmetcmply with
all cryndcuntyordinances ndn telam
O W bmrxnt. but IdIng
to cornplywllh all anduate this PERMIT ISSUANCE /;L,o0 FEES PAID
} 1 Natingtobu Eon t mmtrunlon,arddi property
representative of this
F N city(Wto e)agree
to sae,inde menlbrcd property ed.the Cit purpose. ALTER OR ADD 70 MECH.
? (We)agree to ave,WemNty an d keep harMes the City of Cupertino Date RCCCI Ib
V sgaWt liabilities,Judgment,mus and .per.which may in anyevay.mue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
agawt.dd City In asequence of the gra Ming of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature.!Applicant/Contractor Date EXHAUST I IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the app"morfuture WUding occupant Mort or ha rad le hazardous HEATING UNIT(TO 100,000 SM Date Recd tM
material o de0ncd by the Co Penton Municipal Code,Chapter 9.1Z and the
Ot,aeM Safety Code SSeerio 25532(a)? HEATING UNIT(OVER IW,UD0 BTU) TOTAL:
Will the appliantNWre,building occupant use equipment or deeps VENTILATION FAN(SINGLE RESIU) ISSUANCE DATE
which emit barardous ab mnlamin&nte as defied by the Bay Area Ab
Quality Mawgement District? BOILEER-COMP(3HP OR 10g(Xq BTU) RAQII
Ath�=U
d ealth&rS.us eeSet 25505 Hundcr.,125534G95 of BOILER COMP(OVQi 1fA,000 BTU)
HmHhASa e,Sen 2550.5,25573and2S53C.1utlithe lou b d not ntly haveatenanL tfut it to my NEW RESIDFNIIA CH. SQ.FT to111i notltyt pant dl raquirc ma whkh mr.t ,VwAdp¢cipmo
L f,horiaxd agent Dae UED BY:
TOTAL:
OFFICE COPY
J