21419 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Add r..: 21 419
Z �So rC
Ow me.�` �. �• ^ APP
k ane. CITY OF CUPERTINO-BUILDING DIVISION ' 1 l A D—p0
�• tCn actor Ne Lic.No: APPLICATION /PERMIT - L
�" 3 19 L 1 BIRLDINC-F].FCTRICALPLUMBINGMLCHAMCAL CATEGORY CONTR Ih1Q
A Itect/Engi r. Llc No: KJ
't BUILDING•PERMIT INFO
QTY ELECTRICPERMIT ,.FEE
Address: 0 S I PERMITISSUANCE �
LICP.NSEDCONTRACTOR'S ECLARATION
mVim— /e—�lt
IM1erebyaffirthatl am hcrosedunderprovislansof Chapter9(. .c- APPLIANCESRESIDENTIAL JOB DFSCRR'1TON
ingwith Sedion7W0)of Divisi=3ofthe Businessand PmfeWonsC„ode,and my
license is in fidlipme and effect. PANELS
License Cl Lick 3 4 "O� ��_
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
O rrZzz.. Iundentand myplaroshaBb .saclaspublorecords OVER1000AMPS SQ.Fr.FL�OaO�.R�AREA S/SQQFT.
k, Licensed Professional - SIGNS ELECTRICAL
G< OWNER-BUILDER DECLARATION SPFCIALCIRCUIT/MMC T
Zj; sortIhereby affirm that sexempt from the Contractors License Law for the -
po following reason.(Section 70115,Business and Professions Code:Any city or
O Z"' TEMP.METER OR POLE INST.
r� county which requlmapermltto corotrouires theaprove,demoBah,arrepair—mitto
1 any atmcture prior to tatementshat he is alsamqulreetuant to
provich sions
of its POWER DEVICES
3r4 floe a signed statement eLa that het licensed pursuant it the pon 700)) of the
01 M..3Contrfthc u.insandProessioner 9(commencing e6 exempttherefronof ivi- "I'dgNG TOOL ELECTRIC
L,V, Oa slon3oflheBusinessand Professions Cade)orthathebexemptthere(romand VALUATION
.•--tt the basis for the alleged exemption. Any violation of Section 7011.5 by any
<
applicant permit subjects the applicant to a civil penalty of no rrore than I� OUTLETSSWITCIiFSFIKTURES 61 LV. ^ '^
five hundred dollars(5.500. NEW RE9DENIIAL ELECTR W
�n ❑I,as owner of the property,or my employees with wag.as their sok STORIES TYPE CONSTRUCTION
compensation,wtlldothe work and the structure is not Intended or offered for .
a0 sole&c.7614 Business and Professioro Code:The Contractors License Law
5� does not apply to an owner of property who Wilde or Improves thereon,and OCC.GROUP , RFS.UNITS
who doessuch work himselfor through hisown employees,provided that such _
') improvements arc not Intended orof(ered forsale.If,however,thebuilding or TOTAL:
TOTAL-
improvement back!within oneyearufcomplation,the owner-bullderwill have
(EELturden of proving that he did not build orimproo,for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to construct the projM(Sec.70K Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER MA)
ballds or Improves thereon, and who contracts for such piojects with a
gL�factor(a)licensed pursuant to the Contractors Limn.Law. BACK FLOW PROTECT.DEVICE FEESUMMARY
c I,,.J I am exempt under Sec B&P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Cosner Date RECEIPT p
Mrlt ; WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP S BOOL TAX Y N
kyr aenby affirm that I have o oertiBanc of consent to opythsure,(Sa RFCEEPC p
ce00,Lab o(Workeni Compersatlon insurance ora.rtlfled copythereo((Sec. GAS EA.SYSTFM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C)
Paltryp �� — RECEB'Tp
Com sen N.v GAS EA.SYSTCM-0VER6(FA)
BUILDING DIVISION FEES
1(dCnlfied copyb herebytumecity CREASE/INDUSTRL WASTE INTERCEPTOR PLANCH CKFEE
Certified ropy b filed with the city Inspection division. 1 p
CERTIFICATE OF E')(EMPTION FROM WORKERS' CREASETRAP PAID 11 8/�o5g9y2
COMPENSATION INSURANCE SEWER-SANITARYEA 2OFT Date Recel t# 8l dD
(TMs sectinoneed not be completed i(the permit b forone hundred dollars a
(5100)ortifytperformanceIceify thWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
at In the performance of the work(orwhlch this pennitbbsued,
I shall not employ any person In any manner m as to become abject to the WATER orkeSYSTEM/TREATING / //ss a^ppqq Z
Workers'Compensation laws of California.Date PAID �/ 7� SOa�
0 Applicant
Z NODCETOMPLICANT:ILager.Uk gthb Cert inteof Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date R
' n io
F should become subject to the WorkersCompenatioprovianaofthe Labor TOT
N Cade,you at forthwith comply wlthsuch prow-Lslom or this permitahall be
> decmed revoked. I DIN
LU
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrm that there Is a consttudlon lending agency(or the perform- ELECTRIC FEE
D 0 an.of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL
u2 handers Name PLUMBING FEE
LL f Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE C39
O W I certifythat l have readthb applicationand statethattheabove information
bmrma.Iagrmtocamplywlth aR d admunty crdlnamesandstatelaws PERMIT WUANCE �Z� FEES PAID:
} 1 relating to building rorotm hereby authorize mpretntati`n ofthb
H Z city to en rxpowths Honed property for impaction pu I ALTFRORADDTOMECH. sQ6
— e)agree to save,In it a ep harmless the City of Cu or Date Recei t#
againsthabilitieafpdgmenb, a ex m a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga but said City In conaryue_c ..ting of this permit.
AIR HANDLING UNIT(OVER Ifi"CFhi) CONSTRUCTION TAX
-- Slgvture�lAppR /C ntn or^ Dat IXHAUSTHOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS U4
Will the applicant or future building occupant store or hand in hazardous FfEATING UNIT(TO 100,000 BTU) Date ROCei I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
'I lealth and Safety Coder.�Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
' t
RYes u No
lllthezppllcant mfuNrebuildingoccup.ro.met.,pment ordevices VFIJ7IIA77ON FAN(SINGLE RFSID) ISSUANrP DATE
which emit M1arardous air centainranta as clefimM by the Bay Arca AirAA 11 p
Quality Management District? - BOILER-COMP OHPOR 100,000 BTU)
4 Yes rl No
haveread the th& et materiCode,
25505,25533 and
2554.1 of BORER-COMP(OVQ2700,000 BTU) p 9 p 'I 91
the Call(ornla Flealth&Safety Code,Sections 75505,25533 and 75516.] MATY i O !�!+•
understand that it the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQ.FrE
responsibllity to notify the occupant of the requirements which at be metT��Oq
prio.to issuance of a Certificate ofOccupancy. ?�C—Is�1a�rof CCu]11(a'Wlt
Owneror authorlud agent Data 1' ISSUEDBN �7�-'�✓ EJ`+""t/Y Y9..lK.aV
TOTAL:
OFFICE COPY