21035 (3) > APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/f ' Building I'm'ect Identification PERMITNO.
Building Add OL•-rh
fv^ 21035-
/mere —res: one:
CITY OF CUPERTINO-BUILDING DIVISION
Conntyt rux"aNa u<. a: APPLICATION / PERMIT q- `ppLCIctn
5 ` BUfLD1NGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
�AmchitM/Engineer. Lk.No: '
BUILDING PERMIT INFO"
QTYELECTRICPERMIT FEE -
Addrne:l
- CONTRACTOR'Sp
LICENSED
ICENSEDpBCLARATION PERMITISSUANCE
Ihercr70 dull lkemsedunderprwlaof Chapter 9(romec APPLANCESRES[DENTUL ]OB DESCRIPTION11STI0TO
N
IngwllhSection7000)aDIvWon3 ofthe Buslnee.and PefesslonaCode,and
—'
rtry
limns¢In In loin and effect ppp���^^^ PANELS
Lim Clan LIc.N'-�'
Dale Il� p_Contra CT —Y N
ARCHITE kC15 AT10N 201 OVERiudt PS
Am
LLQpw�00 zpC lundereland my plans shall be used as public records. OVER 1000 AMPS SQ,FT.FLOOR AREA $/sQ.FT.
Licensed Professional SIGNSELEC7Rl
ptkL�R�u OWNER-BUILDER DECLARATION SPECIAI4CE(CUfT/
z p.,q� Ihcmby.fflmthat lam exemptfromthe Contractor's License Law for the
po to following reason.(Section 7031.5,Business and Professions Code:M cityor
rzi"' county which requires a permit tocomutmct,alter,Improve,demolbh,orreair TEMP.M QF LE
IN
anystruaure prior to its Wuance,aLso requlreslheappliant for.uch permit to Ik7WERD
0 file a signed statement That he b Licensed pursuant to the provisions of the
�a Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
.too 3 of the BusNessarad ProfemioruCade)or that he is exempt therefrom and swam NG LEI VALUATION{••� )s-.��
�5�p+ O the barb for the allepermit
su exemption. Any violation of Session net
by any OUTLETSSWHC FIXTURES
`Ldzu appllcantfor a perMlsubjMetheapplicant loa civil penalty of nal=to than IV x+v ai
2 five hundred dollars($500), NEW RLSIDLN7IAL ELECTR SQ.FT.
�n ❑1,as owner of the property,or my employees with wages as theirsok {/ STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for ,
Osale(Sec 7044,Business and Pectmiam Code:The Contractor.License Law
does not apply to an owner of property who holds or Improves Ihercon,and G OLH. RrS
who doessuchwork himself orthreugh hlsownempleyees,provided thatsuch
Improvements are not intended reoffered for sale.if,however,thebulldleg orTOTAL:
Improvement Jai sold within oneyearofcomplelion,the owner-builderwlll have Rtheeburden of proving that he did not build or improve for purpose of age.). QTY, PLUMBING PERMIT
LJ I,as owner of the property,am exclusively contracting with licensed
PERMITISSUANCE r Iaa
rentractostomec
nstruettheproject(S .7044,BudnessandProfessionsCode: TE 3�
The Ca tractor's License Law does one apply to an owner of property who
ALTER-DRAIN&VENT. [EA)
Wild.or Improve thereon, and who contracts for.uch p(ojects with a
coyy{{(Iactor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEES Y•
LJ l am exempt under Sec. B k P C for this reason
OUTS I OF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY . Y N
Owner Date - RECEIPT M
WOR KMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCITOOL TAX Y N
❑1 hereby M.that 1 have•certu a c of consent m opythwrc,or RECEIPT p
certificate of Workers Camperuallonlrinurance oracertllled copy thereof 'GAS FA.SYSTEM-1 INC4 OUTLETS PARKFEF, Y N
3BIJ0,Lab C.)
Policy p . . DECEIT M
Com n GAS E.A. YSTEM-OVER4(EA)
�Cy BUILDING DIVISION FGiiS
ertlBed copy b herebyth thehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified ropybfiled with the dty,Inspection division. '
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM G.X10Ff. D2fC - RCCC1 IN
(Thle section need not be completed If the permit b(arose hundred dollare
($100)aty that
WATERIIEATERW/VENT/E.1CTR , ENERGYFEE Y N
(certify shat In the performance of the work for whkM1lhli permit ie issued,
]shall n rp o) ¢non In any manner n/////!!!!!.....tc be%me gubled In the WATER SYSTEM/TREATING PAID
Workers tlo we of GlBomia.Dald]�
C) Z AppllNOTICmt
E
11 NEW RESIDENTIAL PLMB. SQ.FI'. Date Recei lit
Z O NOTICETOS C ,ager making this Certificate of Exemption,you
should berome suis' ih Workers'Compenution provisions of the Labor - TOTAL:
tll Code,you mu at forthwith ply with such provisions orlhis Permit shall be
W > deemed revoked. BUILDING FEE w n
fl C CONSTRUCTION LENDING AGENCY SEISMIC FEE Lim
Iherebyeffimmthat thercbaconstroctland(Secgagency 7,Civ. .) perform, ELECTRIC FEE __$st
Z once ofthe work for whhem J, contra Weed(Sec.3097, t TOTAL 1
V O Lender.Name - - ` PLUMBING FEE
LL H Lenders Addreas QTY. MECHANICALPERMIT FEE' MECHANICAL FEE
OW Icerti(ythallhave read thbappllationaM rtetc thattheabrve Information
IL is correct.I agree to comply with all city and county ordlnanm..cd nate laws . PERMITISSUANCE �, FEES PAID:
} W relating to building construction,and hereby authorize reprcsentativesi of this -
Z city to enter upon the abovecmenlioned property for Inspection purpose. ALTER ORADDTD MECH. Date ROeel ted
_ (We)We
Ind madly an d keep baroness the City of Cupertino -
agal me,cusb.nd expenses which ray In anywayaccem AIR HANDLING UNIT(TO 10,0W CFM) SUBTOTAL'
agnst uquence of the granting o(ehl emit AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
Signal of Ap o%actor to EXHAUST HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
AZA OUB MATERIALS DISCLOSURE !_ ITT
Will the a pplian r turc building oavpantmone or handle li.rdou. HEATINGUNIT(TO100,01HITU) Date ROcei IN V `
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
,I1ralth and Safety Code Sedlon 2S537(a)7- HEATING UNIT(OVER 100,000 BTU) TOTAL"
❑ Ye No
Wlllthc.pplicant m 1utumbuildingoccup.m.seequlprem ordevices VENTILATION FAN(SINGLE READ) ISSUA
which emit haeardous air contaminants as defined by the Bay Area Air
.� Qua Illy Ma wgemene Di9M07 BOILER-COMP(311P OR 100,IX0 BTU) (�r(� t •IOQ0
❑ Yes n No S r lx 049
� (" lhuve reatl the hazardous materials requirements under Chapter 6,95 of BOILER.COMP(OVE2100,000 BTU)
the CallfomIs I lealth k Safety Code,Sections 255D5,25533 and 75534.I p
u extents no that if the building does not currently have a lenanh that it b my NEW RESIDENTIAL MF.CH. SQ.FI'. !!l fTf Qf(Ona{:naa
n,po iblit y to notify the occupant of the requirements which must be met Lx�`na c"LR7li!r-1
prior to seance o(a Cu tlfiateofOavpanry.
Owner oraulhorl ed.gen Date I
TOTAL: ISSUED '7'
-x
OFFICE COPY