21329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
R"gding AddromcS. 21329
09 80 �e �e .meg CLL
nen ams: l\ 1 one:
Ukta.,lOS _ss k' (Mr) 511-p11I CITY OF CUPERTINOBUILDING DIVISION Q
Contadar'e Na / APPLICATION /PERMIT
BUILDINGELECTRICAGPLUMBINC-MECHANICAL CATEGORY CONTROL N
ArchlteR/Engineer. Lk.N.
S' O BUILDING PERMIT INFO
QTY,,. '�-,ELECTRIC PERMIT �" PEE :,
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Cha pier 9(comment, APPUANCHSRESIDENHAL JOB DESCRIPTION
with Section 7000)of Division 3 oflhe BushamW
and ProfeonsCode,and my
- Lunele In full Torosand.less. PANELS yrs
License Cion LLCM �,/a�`�j�\��
Date Contactor —UP TO 200AhU
ARCHITECTS DECLARATION 701-1000 AMPS '
�ZOC I understand my plana shall be used a public record& OVER1000AMPS SQ.Fr.FLOOR AREA S/SQ.FC.
Emmet]Pro(enlmul nSIGNS ELECTRICAL
<Lklu OWNEDECLARATIONBUILDER DECLARATION SPECIALCIRCNT/MLSC -
Ihereby affirtnlhatlam exempt Coni ractofa License Law the
following reason.(Section 70315,Business and Professions Code:Any city or
O hcounty TEMP.METER OR POLE INST.
�� anystmhlchpe tolWp aRtomnemquireatheatruct,alter, pbmntfmsuch,er ttr .
a fileany atruRurctatemeit that he
aicemed pursuant
of
POWER DEVICES '
U Co c actor.statement that M b Iidenwd pursuant to the provisions of the
Ow Contnctole Lkenae Law K:hapter9(romrrcndng with Section 700D)of Divi.
scon3 ofthe Bueinem and ProfnalonsCode)orthat he beremptthere(romand SNC POOL ELECTRIC VALUATION
�56pu O 5 the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETS.SWITCHESFIXTURFS O.Fvn`
applicant fora permit subject next applicant to a civil penalty nmore than /')�f I.I l..f/ Cw
poi f1 ndrcd dollars WOO).
ae owner of the pmperty,or my employees with wages as their sole NEW RESIDENTIAL ELECTR__SQ]rl'. STORIES TYPE CONSTRUCTION
co neallon,will do the work and thestrumtre is not Intended or offered for
Osale(Sec.7044,Business and Pm(enlom Code:The Corn dots License law
$$ does out apply to an owner of property who builds or Improves thereon,and EEE OCC.GROIP RFS.UNITS who donsuch work himself his own employees,provided that such
Improvements arenotintendedorofteredfersale, lfhowevegthebuildingm L•
- TOTA
Improvement bsold within owyearofcomplelbn,theowner-bugderwillhave
t1L jxurden of proving that he did nM build arimpmve fur purpose o(ealeJ. Q3'y; PLUMBING PERMIT FEE FLOOD-LONE APN
LJ L as owner of the property,am eacluslvely mntraRing with Ilrnnaed PERMITISSUANCE,
contractors to construct the project(Sec.7044.Business and Precessions Code:
The ador'.License Taw don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bull or tprovn thereon, and whom et for such penjecs with a
nor( ucyegd punuantt n oYs License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
eo/f (un a B k P C for thio awn
DRAINS DOOR ROOF,AREA,COND. - SANITARY Y N
OUTSIDF FEES
_ITEC Rl?CEIT N
WORT AN COMPENSA ION DECD.LA FIX`URES PERTRAP SCHOOL TAX Y N
❑I hereby affirm that I have• lesucate of connn to set-thea,ora RECEIPT N
certificate of Workera'Compensatlon Insurance ma certified copy thereof(Seo. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800, ab CJ
Policy N RECEIPT N
Com an GAS.EA.SYSTEM-OOVER y BUILDING DIVISION FEES
Certified copy is hereby te
Certified copy b filed withh the city
inspection dlvltlon. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ity
GREASETRAP r �p
CERTIFICATECOMPENSATION
I N FROM WORKERS' PAID/b-2 o ts,,y�_�
COMPENSATION LNSURANCB SLIVER-SANITARY-STORM EA 7(IOFT Date Revel t# J`R O
Rhbeedlan need nn Mcomplded if the permit bforene hundred dollars _
(S100)ml..) WATER HEATERW/VFNT/ELECTR ENERGYFEE Y N
lartgythat In the penomunce of the wmk forwhich thio permit is blued,
I shall not employ any.Lawn In any manner w u to become subject to the
Workers'Compensatlon laws of California. ATLR SYSTGL/TREATING
,Date - PAID -
z Z Applicant - NEW RESIDENTIAL PI.MB. 50}T. Date Recei t#
Z p NOTICETO APPLICANT:If,after,nu king this Certificate of Exemption,you
should become subject to the Worker'Compensation provisions of the Labor TOTAL:
N
Code,you must forthwith comply with such provbton orthb permit shall be o0
j doetra.'d revoked. LE
dC CONSTRUCTION LENDING AGENCY SEISMIC FEE - .7
I hereby affirm that there b a construction lending agency for the perform ELECTRIC FEE
Zahis.!theworkforwhichthbpermltlsbmed(Sec.3097,Civ.C.) .TOTAL:
V O Looder'a Name � - - PLUMBING FEE '
LL H Lend./.Add.ss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O Lit
I rnrtitythaH have read this application and statethatthe above information
IL bcomect.Iagrce tocomply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
} W reSidconstruction,and hereby autharlu rcpresentativa of this
Z cie abovo-rrentioned property for bupectlon purpoeea. ALTE40RADDTOMECH. -
_ ve,idemnify an d loc ar the City of Cu pertlho Date Re0e1 tanM,mates de ase 1 may In anyway accme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:aco t of Iepennit. AIR HANDUNCUNIT(OVER IQ000CFM) CONSTRUCTION TAX
51 fqplicant/ ontrador - Da EXHAUST HOOD(W/DUCn CONSTRUCTION TAX PAID: -
HAZARDOUS MATERIALS DISCLOS RE
Will the applicant or Future building occupant store or handle haearelous HEATING UNIT(TO 100,000 BTT!)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date RCCei T#
Health and Safety Cade Section 25537(a)7HEATING UNIT(OVER 100,000 BTIJ) TOTAL
F1 Yes N No ••
Will the applicant nor future building occupant use equlpmentordevices VENTILATION FAN(SINGLE RFSID)
ATE
which which emit havardous ab contaminants a$defined by the Bay Area Air
Quality Management Dlstdn7 BOILER-COMP OHP OR 100,00D BTU)
❑Yrs r7 No ��� t
Ihavomad Ithe Imhazardfetycus Code,Serequlremenb5533 and 25534.Chapter
of BOILER-COMP(OVER 1W,000 BTU)
- 16 1991
xiy.the CaliforniaW I Iealth&Safety Code,&aona 75505,75573 and 75534.1 '
understand that if the building does not currently have a tenant,that It b my NEW RESI DENTIAL MEGH. SQ.IT.
rapmisibllily,to sad ify the occupant of the requirements which moat be metMilt �laaaai:aaw
prior to Issuance d a Certificate of Occupancy. Of.USP."
Owner or aulhorimdagent
Date TISSUED 6
OTAL: —
OFFICE COPY