21801 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification A ' '` -I PERMIT NO.
/ Building Address: 1071O.-So Ae t7t 2� g(vCr
21801
one. CITY OF CUPERTINO.-BUILDING DIVISION
Coneractor'sNams: 4i=`.No: APPLICATION if PERMIT 66
BUILDING-ELECTRICAL.PLUMBINC-MECHAMCAL CATFLORY CO M
ArchIMCL(hngineer. Lie.Nic
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 3D 5Aa %df{i✓h.�Do Riva
9 = POWTISSUANCE I Z•
LICENSED CONTRACTOR'S DECLARATION
Iherebya(flren that l am licensed under provaler"Chapter9(mmmenc- APPLIANCESRESIDENTIAL JOB DFSCRErrION
Ingwith in Iformald efelon3o(theguslnesaand ProleulonaCode,andmy
license is in full(once and Brett. PANELS
License Class Lie.N
Date •1,j C°ntraRor_ UP TO 200 AMPS
ARCHITECPS.DECLARATION N]"1000 AMI'$
cc la understand my pbnsahall be used upublic records. OVER]000 AMPS SQ.FT.FLOOR AREA 5/S
tQ.FF.
E� Licensed Professional SIGNSELECTRICAL 1915 6(-4x3O
WNE
GGGG 6 OR-BNLDER DECLARATION "'���FFF���
CaSPECIALCIRCNT/MISC
Iherebyaffirmthat l am exempt(ronethe Contractor's License Law for the
p following ichreq(imap 7llaltommnessandnimp oe de=i:Mycity it
� TEMP.METER OR POLE INST. '
any.tructum requlreaa permhtomnstnct,esithemprov nt fessuch hh,ar repair
q' a any etsigned tatemeprierto itahat heirnce,also reqs pursuant to the
provision of
te pQ1ygR DEVICES
[S Ui fits a signed statementthathet licensed pursuant it the tion 70 ns of the
3w..
Contractor's License Law(Clupter9(commencing with Section form a!Dlvl- SWIMMING POOL ELECTRIC
I-thOJ sion3 of the Business and Professions Code)or that he h exempt therefrom and VALUATION
<$� the basis for the alleged exemption. Any violation of. cllgo7D3i1,5,bv pry '� ^ I '1 do
applicant furs permit subjecutheapplhant to a civil rslty nn 1 tha O 'k• C..b ( { • �"'�'
ofive hundred dollars($500), L / L= It
..�n ❑I,as owner of the property,or my employees with wa ea as their wk g. - ���'�' STORIES TYPE CONSTRUCTION
t mmpcnuHogwRldutheworkandtheatmcturehma ten�ed:off
for ��
$9 O ss1.(Sec.7014,Business and Professions Code:The ContranoF,License La`w ' It
does not apply to an owner of property who builds or l proveathereon,and OCC.GROUP .UNITS
0. who daessuchwork himaelf°rthrwgh Meawnemplgl �tfa�'Ich -- _ — _
improvements are not intended muttered for sale.ILh ever,the WIIding TOTAL: c
Impmvementh.old Mthinoneyearofcompinlon,theowner- uildeiwflhavo
t4gtfunden of proving that he did not baud or Improve for purpose of sada.). QTY. PLUMBING PERMIT FEB
"L as owner or the property,am exclusively contracting with llmnutl FLOOD TONE APN
ournectwa to construct the pmject(Sec.70/4,Bu.tnessind Professions Code: PERMIT ISSUANCE
The Contractor'.License Law doe.not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA) CA/1
Wilda or Improve thereon, and who mntrsns for such p(ojects with a FEE SUMMARY
cgRt(a&or(.)licensed pursuant to the Contractor's LI...Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B k P C for this reason
OUTSIDE F1 ES
SAMTARY Y N_PlS �f-o
Owner Date /Q DRAINS FLOOR ROOF,AREA,COND. 0, RECEIPT N •/
WORKMAN COMPENSATION DECLARATION T Ir
❑1 hereby affirm that I have a certiRmte of consent to self-Insure,ora FIxTDRES PER TRAP `�j�r®J SCHOOLTAX 2FLf9•NM
mooBubC'Worken'Compewtlonlnsuranm ma certified ropythereof(Sec. GAS EA SYSIETNI INC4 OUTLETS .(2V PARK FEE Y N
Policy M GAS EA.SYSTEM-0VER 4(FA) RECEBrr p
Co say BUILDING DIVISION FEES
Ted copy h hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' CREASE TRAP 2. Cc PAID •�
COMPENSATION INSURANCE SEWER-SANITARY STORM G.200FT. DaM Repel t#
(Thlssection need not be completed If the permit h furore hundred dollars
($100)or leuJ WATER HEATER W/VENT/ELECTR 6 ENERGYFEE Y N
I certlfythat in the perfumunreof the work forwhich this permit is Issued,
I shall not employ any person In any manner sou to become subject to the WATER SYSTEM/TREATING
Worken;Compensation Lam of California. Date PAID 'T� 11
ZZ Applicant NEW RF9DENTIAL PLMB. SQFT. Date Recel t# ��I00
O NOTICETO become
ct to the
oriftermakingta CercNoteaf...ftlan,you _
shoulddoumus 0forth forthwith
co Workers'such proistat npmvhiorormit s GWr TOTAL: �2•
N Codgyou mu.lfonhwith comply with such provhlons or this permit shall be 1 D (�•
W ] deemed revoked.
fl CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE Q9
Z an ofthework(orwMchthhpermitio s ed(Sec.3097,Clv.C.) IOTA t
of
C.) O lender'.Name PLUMBING FEE 17LtLOD
LL ~ Lender'.Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE (�
O W lcedifythatlhavemadthb.ppBmtbnaMtlatethattheaboveinramution .••s .�y
a is named.l agree to comply with all city and county ordinances and state laws I PERMrr ISSUANCE uCV FEES PAID:
renting to building construction,end hereby authorize representatives of this
Z city to enter upon the above-mentioned property roe Inspection purposes. ALTERORADDTC)MECH.
Me)agree to save,indemnify an d keep harmless the City of Cu pimino - Date Receipt#
V against liabilities,judgments,costsand expenses which may In any ways.. AIR HANDLING UNIT(TO 10,0DO CFM) TOTAL:
against aid City Im mreequemn of the gran gdth1.permit.
N on ry1 a 6 /� O !L— = AIRHANDLINGUNIT(OVER 10,000CFM) ONSTRUCTIONTAX 1
it Signadifi,6r ppBant"omrtrador Date D(HAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ^�
Will the applicant or future building occupant store or handle hazardous BEATING UMT(TO 100,000 BTI!) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter9.IZ and the
Hca❑It Maenad Safety CodeSection25531(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
NO
Will the applicant oruufutvrebuddingompant ussequlpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which rout haxandous air contaminants as defined by the Bay Area Air
Qu IlyManagement District?
BOILER-COMP pFR'OR 100,000 BT11)
❑Yea ❑No
lhavc read the M1azarclous materiaLv requirementsunder Chapter 6.95 of MOILER{OMP(OVER I00,000 BTU) I�
the California Health A Safety Code,Sections 2S505,25S33 and 15534.1 N Q O �a���
understand that if the Wilding docs not currently have.tenant,that it h my NEW RESIDENTIAL MECH. SQ.FT
sib 'v4 fa•%t�0
r spor0lty to notify the occupant of the requirements which must be met
prior to Lsson nue of a Certifiate of Ocm parry. L �('
.a��
Owner or aulhortud agent Date _�
TOTAL: ISSUED BY:
OFFICE COPY