21293 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PFlUvUT NO.
Bel 14d1,.: o � sl c - - 21293
one:
APPLICAIIUN hUB.Mil IAL
re.. ante. CITY OF CUPERTINO-BUILDING DIVISION _t
con ad o.Name: Lic.No: APPLICATION / PERMIT
Architect En BUILDINGELECTRICALPLUMBING-MFGHAMCAL CATEGORY CflY/lpl 9
No: �ON
QiY ELECTRIC PERMIT FEE BUIL ING PERMIT INFO
Addrh. l(v10 WI PFRMITISSUANCE �Z�
PLUMB '4�
LICENSED CONTRACTOR'S DF.CARA ONe
Iherebyaf( tha,lam llcensedunderpmviad of apter9 omen APPLIANCES-RESIDENTIAL JOB DPSCRITION
ingwlth Sen )ol Dl lalon3 h ���,ssy� salons ;and ery
li¢nse I,In t rad dfen. L� 1 PANEIS
Limn C Ic.N `�
--tractor •C �a -
ARCHITEOPSDECARATION 2VERl0AAM
qqq 0'Z MPS
]undcntand my plaa,hall be used as public..cords. OVER 1000 AMT'S SQ.FT.FLOOR AREA. 5/SQ.Fr'.
ZLicensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
I, ]hereby atflrmthatlam exemptlromthe C.ntrador'e LI¢nse hw(o the ,/'�
7_O.. followingreason.(Section 701.5,Ehne..s and Profession,Code:An d or
07.1..� y city TQdP.MEEIZ OR POLE INST, ti W
county whichcture requlnsa permit e,alsore ct,alter uirestheapmvgdennWh,ormitto
q y � anya si ned statento menIts Issuance,licensed
pursuant to
nwidoor such p of the
PO)VFR DEVICES
k C G file a,]gated statemnse ent that he b Ilmnaed punuant to the n A of the
3 Con3fthe ui ne.law mfew r9CWe)ordngwith Section7SWhMING VOL$LEC RC VALUATION
F,�O< slon3ofthc8uslnes.end Profe,ebroCade)orthat Febesemptthere(mmaM ^V /
.X the basis for the alleged exemption. Any violation of Section 7071.5 by any OU7LETS5WITCHESFTXfURES ("��- T 14 fi s
appllant fan permit subjects the applicant to a civil penalty of not nure than t
F o five hundred della.(W.
❑I as owner of the property, NEW RESIDENTIAL ELEC7R �FT. STOW TYPECON'SIRULTION
, p perry,or my employees with wages as their sole
CZ mmpcnsatIon,wWdothcwork andthestruatum bnotlntenddce offered for
CD sale(Sc.70441.Business ad Psnf.i..Code:The Cont.d.e.License Naw
$ does not apply to an owner of property who Wilds or improves thereon,and
c-$^ who doe,such work himself ce through his own employees,provided that weft OCC.GROUP RES.UNITS
impmvemcnts arcnot lntcndd...ffered fee sale.If.however,thebuildu g or TOTAL:
improvement b sold within oneyearofcompldlon the owner-builderwlll have
mcc*rdenotpmving that hedid ovs Wild orlmpmvef¢purposeofsab.). QTy. PLUMBING PERMIT FEE
LI L a,owner of the property,am exclusively contracting with 11¢med FI-OOD 7DNE APN
centra don to censused the project(Sm 70K Business and Profesiom Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VEM-WATER(A)
builds or Improves thereon,and who contracts fee such pie*cts with a
,¢IliIa0o 1,)licensed punuant to the Contractor'.LI¢nse Law, BACK FlDWPAOT[CT.DEVICE FEE SUMMARY
IJ I am exempt under Sec. B Sa P C for this mason
DRAINS.FLOOIL ROOF,AREA,GOND.
SANITARY YN_
_
® Owner Date RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP S—
F-11 F-11 TA% Y_ N_
hereby affirm that I have ¢dNca of consent to sel(dwre,ora RFCE0PT N
3800,
certificateofWertrnCumperoatlon]rourance¢acertlfid copy thereof 4See GAEA.SYSTEM-1 EE Y INCA OUTLETS PARK FN
380
Policy#bN C.) IrGAS A.SYSTIM-OVER N(A) DIxIDT N
Com any BUILDING DIVISION I'EliS
�Certlfied copy is hereby filed
the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is heed with the dry inspection division. N26j
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID� �(�
�W
COMPENSATION INSURANCE SEWER-SANTTARYSTORM EA.2WFT. Date Remi 1 (n.
(This ectlan need rad M complied](the permit b for one hundred dollars
RIWJ«lea.) WATER HEATER W/VENT/ELDCTR ENERGY FEE Y N 5fl•�
I certify that o the person I.any
m work so as to b ce permit ubj is assort,
I shall not employ any person in any manner n a to become subject to the WATER SYSTEM/TREATING
Warkcn'Compen»tlon hast of Glifomla.Date PAID
licant
Z Z NO TO APPLICANT.If,after making this Certificate,of Excmpt.,you NEW RESIDENTIAL PLMB. SQFT. Date Revel tit
H O should become on
bject to the Worke 'Compessation provision,ofthe Labor TOTAL:
W Cod,you at forthwith complybiou
with such pnevorthla penNsh
tall be BUILDING FEE
LU j deemed revoked.
a o CONSTRUCTION LENDING AGENCY SEISMIC FEE /
IM1<rcbyaf8rmthat there ba ceratrunlon lendingagency forth pedorm ELEC'T'RIC FEE s
7 Z an¢.fthaworkforwhichthbpermitlsL ed&c.3097,CIv.C,) TOTAL: 7�
V O Lcndera Name PLUMBING FEE _
LL F I<nder'.Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ,�--
O W ]red.I agnentvemply with
all
and county
yordinances and date
CL mingtobgnetocornplywlth alltltyabyauthyodinan¢eand LLsofthie ( I'FRMR LgSIIANCE 12OQ FEES PAID:
} relating tobulldingcerotmctlon,and hereby authorize representatives of this n
f. Z city to enter upontMa ovcme elected property for inspection purposes. ALTLR OR ADD TO MECH. 9,0o Date RefCl IN
— N'. 1h
ve, comfy trep harmless the City of Cupertino Faga ,jadigrat; ,lsea which maW
rue AIR IiANDLING UMT 8010,000 CFM) SUBTOTAL:
agaIno u ¢oft gantingofthispeAIRHANDLINGUNTT(OVERIO,"CFM) CONSTRUCTION TAX
nS, pli¢nt/C.ntracmr IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H AZA R DOLS MATERIALS DISCLOSURE
Will the applies rat or futu re bu ilding occe pant store or hand In hazardous I MATING UNIT(ED 100,030 BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Halth and Safety Cdr Section 75532(,)7 HATING UMT(OVER 100,000 BTU) TOTAL:
Yes �]No '
Will the applicant onandldingoovpantuse the Bay Area devices VENTILATION PAN(SINGLE RESID) ISSGANCE DATE
which emit Mgement airrict? wntaas dented by the Bay Area Air
Quality Management Dbirin7 BOILER-COMP OFI'OR 100,000 BTI.
4hYa Q No �s
ave read thehua ou,materials requirements under Chapter&95 of BOEFRCOMP(OVIX tW,000N
B ) .s
,he Califomla I health&Safety Code,Sections 25505,25533 and 25534.1
uMeaand ttitl(thc buildingdoes rad cerrtntly haveatenant,that it is my NEWRFSIDENTIALMECA. SQFT
responsibilityrtIssuance
of aCehcoccupantteofOcftherequlrcments which most be srrt
prior to bvencc eel yly the of Oa the req ^77.��(]�(y� � ,,,,s
Owner....thrmrcd agent Date ISSUED BY:V IA✓YIw\s••A1`✓�'a's�
TOTAL: ob
OFFICE COPY