21072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proiet IdmOfknisn PFRWT NO.
Build ng Add - 21072
q, 753 —4611
roe. name: :
8 «,. CITY OF CUPERTINO-BUILDWGDIVISION
Contractor.N. Lie.N. I APPLICATION / PERMIT
BUIIAING-ELECIRICAL.PLUMBINGMECHANmAL CATEGORY CONTROL 9
Aachned/Englmuer. Lk.N«
Qry ELECTRICPERMIT FEE BUILDING
BUILDING PERMIT INFO
Add.Ila . PIXhBTI.5STIANCE Oft, ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that l am licensed under proviakms of Chapter 9(comm,n AFFLI N ESRESIDENFIAL JOB DESCRRrFION
ingwith5eetbn 70W)of Dlvlelon3 ofthe Busimsand ProfensionsCode,and rrTy
limme b rs in full fuand d.a PANELS
Limns Lb
CWS
Date Contractor
ARCHITECTS DECLARATION Ml-I"AMPS
QGZ I understand my plana shall be used 0AMPS as public records, OVER100SQ.FT.FLOOR AREA $/SQ.FT.
V
Llmnsed Pm(edonal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
pF, 5 I hereby affirm that l am exempt fromthe Contrenor'sLarue Lawforthe SIk.CIALCIRCNT/hilSC
oo r�j� following reason.flan 70115,R e..and PmfedruoCode:Any tlty or t Qsa
'[EMP.MEPOLE OR LE INST.
Fig countywhkh mrqukea permBtomvrequiratheapmvgdertnlbh,ormit to
aLan< any atadurt pater totthat res,licersd rursueat to the frosuch
raeof t e pOy/pR DEVICES
rG 6 O fib•signed statement that he b licensed pursuant to the proviabro of the
O Cuntractor'a Lkeroe Lw(Clu 9(mmnendn whh Sectbn 7000)of D1v1- V
ALUATION
%OC' sbn3 tithe Butlness and Prof®lora Code)orthH hsbere thertfmmaM SWQ.IIANG POIX.
S the basis for the alleged exemption. My violation of Section 70115 by any t
<.4 appnantfora pemdt wbjMathe applicant tea dvil penally dnut mon thin O�''WITCFDSH
w five hundred dollars(S_W.
FI,u owner of the property,or my employee with wages as their Bole NEW RESIDENTIAL SQFF. TYPECONSIRUCTLON
k7Q cvmpensrtfon,will do the work,and the.taehart is one Weeded or offered for
,,a ❑ sak(Sec 70K Busbieas and Profmbro Code:The Contradar.Wane Law
p R does wtapply to..ownerdpmpety who bulldaor imprwesthmon,and
FS^ whodxasuchworkhlmeelforthragh hl.ownemplryce,prwlded thatwch CCCGRQ%W REB.UNITS
Improvrrrcnts art not Intended oroHered foreale.If,however,thebulldlng or TOTAL:
Improve 6sobwlthnone5tarofcomplebntheowror-0 MerwaI have
t adendprovingthat he did not WBdorbnprewforpurpseofses.). QTY. PLUMBING PERMIT FEE
Lj 4 as owner d the Property,am exclusively contracting with limned FLOOD ZONE APN
contractee to construct the project(Sce.7014,Buslnesseul Peo(esBbro Code: FERNUTLSSUANCE
The Contractor'.Lloerue Law does not apply to an owner of property who ALM-DRAIN kVENT-WATER ffN
builds ce improves thereon, and who contracts for such pt,ej r with a FEE SUMMARY
ryNF+ctor(s)Hemard pursuant to the Contractor's Lianas Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec B k P C for thisreason
Owner Dee DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ ,
WORKMAN COMPENSATION DECLARATIOPER;W_ N
171 hereby affirm the I have a oertlRnte d c .of to self-Lore,or s SCIi00L iA% Y N_
oenBlcate of Warken Compeneatlon Iraunna as anl(led mpythetmf�cc. REC�a
3800,Iab G) GAS FA.SYSTEM-1 INC-4 OLJ LEIS PARK FEE Y_ N_
putCom a GAS EA.SYSTEM-OVER4(EA) R�EErI'N
rry BUILDING DI VISION FEES
�Cre
,,Med copy b herebydwith the coy GREASE/RJDUSIBL WASTE INFFRC=R PLANCHECK FEE
❑CertNed mpyb(Oed with the tlty inspection division.
CERTIFICATE OF EXSMPIION FROM WORKERS GREASE TRAP PAID
COMPENSATION INR E
( bbnnedradecmpleedUtepembfororc hundred dollrsSEWMS. ARYSMRMEA700T Date Recei tN
($1OO)or1th WATER HFATERW/VENT/ELr r ENERGYFEE Y N
Imrtlfythatlothe performance ofthewerk forwMch thin permit le towed,
1 ehau not employ any person In any manner so as to bemarc object to the WATER SYSIEM/TiEATING
Workcri Compensation Laws of California.Dee PAID-
0
PP NEW RESIDENTIAL NMB. SQFF.
A Rant
Z 0 NOTICE TO APPLICt to
her rs'Comhla Certnlabof Ens oftha Lyouibor
Date TA t#
F N shaldbemus subteen the Work an'such pr atlonpmvbis permit stab be TOTAL:
Code,you veko forthwith comply with such pmvisbro or this permit shall be
� > deemed revoked. BUILDING
CONSTRUCTION LENDING AGENCY S I MIC FEE
CL I hembyefirmthat there is a mmtrudima lendingagemy forthe perform, ELECTRIC FEE
:3 Z .raceof the work for which this permit is bused See.3097,Civ.C.) TOTAL:
U O Lender.tome PLUMBING FEE
LL H Iaader.AEdre. Qs,. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IrexlLI hgmtov vxrd thbappUrit . dmurtethd tninoeselnformatlm
b cormL lagreetocornplyw aBdtyand countyomdlnanmaand erste laws PERMIT155UANCE FEES PAID:
} N rtldl buildingcoat al hereby authorbs representative ofthb
F.. = dtyt a rapers the rat pnopertyfor Wpectbn pups. ALTER OR ADD TO MECH.
V — e> gas to vve, q d keep n es the Clry of Cupenlw Date Reccipttt
blibles d iehmaybanywayaceus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.old city In of F log lab perms,. AIR HANDLING UNIT(Ovt7t 1g00oCF) CONSTRUCTION TAX
SlgnlWmd App1+t/(!ostActoris
EXHAUST HOOD(W/DucO CONSTRUCTION TAX PAID:
FIVARDOUS MATERIALS DISCLOSURE
Will ths.pplinnt orfuture building occupmmmeor handle havrdoue HEATING UNIT(TO 100,000 BTU) Date Recei tic
material as def ord by ted Cupertino Munldpl Code,Chapter 91Z and the
Health and Safety Code Section=12W? HEATING UNIT(OVER 100,000 BTLA TOTAL:
PYen M No
111theapplkiu afutun Wildingo«opantuseryulpment ordevims VENTILATION FAN(SINGLERESID) ISSUANCE DATE
whkh cndt havrdaw atr ttmUMnanb a deRrad by ted Bay Area Air
Quanty Management Wtr4t7 BOILER-NMP(3H?OR IOgIXD BTI
4 Yes Fj Ni.
vert thehav oua malerlab requlrtmenb under Clupler 6.95 of BOILER-CVNP(OVER Hie,"BTU)
the Isalthk5afety Cods,Siaic.25505,75533and75530.I
u n t Ilflhebudding do-- rrtntly have a tenant,that lihrtry NEW RESIDENTIAL MECH. SQ-Fr. Rp�sa,N
to earupntd enqulamentawhkhrrustbe rent
pr Iffated racy.
u hodad agent Dale ISSIJEDBY.
a
OFFICE COPY TOTAL