21113 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification V PERMIT NO.
Building Address: 21. 113
u 2 P � b f3
sonars ams: one:
CITY OF CUPERTINO-BUILDING DIVISION
ntr ctor'sN me: /Iy�- u.. APPLICATION I PERMIT
BUILDINC-ELECTRICALPLUMBINGMECtiANICAL CATEGORY CONTROI.N
• Arr1t/c{� ,Ienr� � — ` / gIe Nu QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
L 4 --.) 'O
Address ^I ,��N�r
1 4 � NX ® LU
LICENSED CONTRACTOR'S DECLARATION I'FRMITISSUANCE
withSJhembyton7 )ofDivdoat I am nsed 3oftheunder sinema dr)rc ms Chapter9( ,anmc APPLIANCES.RESIDENIIAL ]OB DESCRIPTION
Ingwlth 1.f48ITcAof Dividon3ofthe BudnevandQl'ro(esslonsCede,and my
- limnse is In ! and d(ect. �aS / / PANELS
Limq;Cla�Llc
It.
f'
Date Contna.r
ARCHITECT'S DE UP TO 2DOAMM
LARATION 2014000AMP5
X I understand my plans shall he used As public records. OVER1000AMPS SQ.Fr.FLOOR AREA $/";Q.FT.
}t (/ Licensed Prolesaimud SIGNS ELECTRICAL
<<� OWNERBUILDER DECLARATION
ffi SPECEALCRCUT/MESC
zexempt
f'T`Jf({•a
H e
Thereby affirm that xemptfromlhe Contractor', law for the
po following rcason.(Section 70315,Business and Prolessions Code:Any city or
F c.unlywhlch tequlrcea permit mccastruct,alter,improve,demollah,orrepalr TEM['.Mb7FR ORI'OLC INS(.
$$q'� anystruclure pdortoitaUuance,alsorequbesthe applicant for such permit to
I7 O file a signed statement that he la licensed punuant to the provisions of the POWER DEVICES '
3pI,, Gntradoes License iaw(Chapter 9(commencing with Section 7000)of'�yd Divi- SWIMMING POOL ELECTRIC
aton3ofthe Budnnsaad Professions Code e b exemperc
.,that he thfromand VALUATION
� S the barb for the alleged exemption. Any violation or Section 7011.5 by any
p applicantfare permit subjecutheapplicanttoadvllpenalty ofnann¢than OIITLETSSWI7CFIFSFIXMtES log, eta
�G11 c five hundred dollars eISM. _
NEW RESIDENTIAL ELECTR
�n m I,as owner.(the property,or my employees with wage as thele sole —�'FT' STORIES TYI'C CONSTRUCTION
compeec.70 n,Bulmash and
and Professioed ode:Thre not Intended.ioffend for
J] O dais(Sec,apply
to A now owner
fprope property
who
builds Contractorssthemon law _
µ$� don oeut apply loan owner ofthroug iwhob emplrimproves ovidedrcoryand OCC.GROUP RES.UNITS
0.0. who daesauch workhlmself orthmugh Neown emplayeea,provided that such
Improvements am not Intended oroffered fcrvle.If,however,thebuilding or TOTAL: ,
improvement bsold within oneyearofcomplel ntheownerbuilderwill have
the burden of proving that he did not build or Improve for purpose ofubJ. QTY LO
PLUMBING PERMIT FEE FOD ZONE APN
LJ L as owner.!the property,am exclusively contracting with licensed PERMITISSUANCE 'l
contncton to construct the project(Sec 7044,Business and I'mmoslora Code: s CD
The Contractor's Llmea,Law does nm apply to an owner of property who ALTER-DRAIN&VENT-WATER(RA)
builds or Imprwn thereon,and who contracts such pipjem with a
151 ci.r(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
• RECEIPT M
WORIO.tAN COMPENSATION DEECLCL ARATION FIXTURES.PER TRAP SCHOOL TAX Y N
❑I M1ereby arks that I have a mdltkan or consent to pythsu¢,ora RECEIPT tl
certifi1.h C) orkers Compenvtlanlmunnm ora¢rtlfkd copy thereof Oec. GAS EA.SYSTEM-1 INC4 OUTLETS
3800,Tab C.) PARK FEE Y N—
Pollry M RECEIPT p
Cany GAS E I BUILDING DIVISION FEES
amfCerttfied copy is hereby fumlehed. CREAS D L A PLANCIIECK FEE
�CedBled copy b filed with the city Inspection division.
CERTIFICATE OF IXEMPI'ION FROM WORKERS' GREAS PAID ['`
COMPENSATION INSURANCE SEWER-SA RM EA 700FI' �� z 7/ Date Recei 1# �a
(rhlesecti m need n¢be completed tithe permit later...hundred dollen 7
($100)orlev.) WATERHFATERW/VENT/ELECTR ,aPNERGY FEE Y N
Icertltythat Inthe pedornunm o(Ihew¢kforwmch Wspermll is issued, —
Ishall am employ any person In any manner so As to become subject to the WATER SYSTEM/TREATING
Work.ri Compenwtlon Laws o/Gllfornia.Data PAID
O Z Applicant Date Remi t#
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT.
should bacomaindjact to the Workers Compensation provisions of the Labor TOTAL:
V4 Code,you moat forthwith comply with such provisions or this per atshall be s BUILDING FEE Q�
9 dMmrevoked.
voked.
W
p CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ilu,mbyaffirm that there la a construction lending agency for the perform, ELECTRIC FEE
Z ance of the workfor whldh this permit is issued(Sec.3097,Civ.C.) TOTAL:
U Q I.endereName 4 PLUMBING FEE
LL I- landerb Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtitylhatl have read lhisapplicallon and dalethalthe above Information
lacorrect.I agreetocomplywlth allcityand county ordinances and date laws PERMIT ISSUANCE FEES PAID:
� 0. relating to building conslruction,and hembyauthodu representatives of this
N city to enter upon the above-ncntioned property for Inspection pu rposes. ALTERORADDTOMECH.
Z (We)agree to save d;Ar ly d keep ha ass the City of Cupertino Date Receipt#
V against liabilities, nls, exile which yin. ywa accrue AIRHANDUNGLMIT(TO10,000CFM) SUBTOTAL: 1
age rel I one u : f the Ing permit 7 AIR HANDLING UNIT(DYER IO,000CIM) CONSTRUCTION TAX 12-32
O c/
o APpI . .nOUS Da INFIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDUS MATERIALS DISCLOSURE
Will thea bcant or futu¢bulldingomupanI atom or handle hazardous HEATINGUNIT(ID100,000BTIp ' a�
matedalasdellnedbylhe CupeKI.MunlcipalCode,Chapler9.12andthe _ Date Recel t#
Health and SafetyCode Sacdon25532(a)7 HEATING UNIT(OVER 100,000 BTU) T TOL:
.❑Yea in No ,,./1 t
Will the applicant or tum building occupant use equipment or devices VENDLATION FAN(SINGL.E REM[)) 1 SLrAoNC(9](Df}ATE
whichemithaaard...1,contamlranbasdeflned bylhe Bay Area Air
hty Management DLatrict7 BOILER-COMP OHPOR 100,000 BTU) e-N
YrsI�No
have read the hva us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Glifernh Health h Safely Code,Sections 25505,25533 and 75534.1 / r,J.(
understand that if the building does not surreally have a tenant,that It la my NEW RESIDENTIAL MECH. SQ.FT @—!tel Utz:—,v
responsibility to notify the occupant of the requirements which must be met
prior t.Lvuance of a Certificate o(Occupancy, �'�-aha-s Q.�s
Owner or authimud agent Date I ISSUED BY:VVp, IN"r��
TOTAL: 1
OFFICE COPY