21885 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Trued Identification PERMIT NO.
Wilding Address: f1 a� (�(")
ZcA31 f� l8
C I�I cA L1i2 . G I lel(
one: APPLICA IION SUBMI]IALA
HA"I CITY OF CUPERTINO-BUILDING DIVISION
Connadrr;Name: Lie No: APPLICATION 1 PERMIT
BLfILOINGELECTIUCALPLUMBINC-h{ECrypMCAL CATEGORY COM1'TROLX
'Architect/Engineer. Lie Na: �3
{� 2 -1 ELECTRIC PERMIT- PEE BUILDINGPERMITINFO
Address, �16 �1 `�� - PFRMTISSUANCE -Y_Q
LICENSED CONTRACTOR'S DECLARATION : Y—' Li
I hereby affirm that l am licensed under provisions of Chapter 9(commenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ince.l Sedlonforecafd effeon3ofthe BualnessandPro(nslonsCode,and my F� w
IC
Cil(u0loan and dfect. PANES 1f' �.\v
Llano Class LICX -
IALED
Date Contndor _
ARCHITECPS DECLARATION 201-I WO AMTS
Z I understand my plans atoll be and u public records. OVER]l1W AMIsS �9Q FT.FLOOR AREA 5/_Q.FT.
pp OC aKl
'bb Licensed Promeakneal NGNS ELECTRICAL _
ue-
C OWNER-BUILDER DECLARATION SPECIALCIRCIIT/MIST 8
t.,'� ; Ihereby affirm that l am exempt from the Contractors License Law for the 1 L�•�
.gt-9 following reason.(Section 70715,Business and Professions Code:Any dry or (}�Ip METER ORPOLE INSf. 1
aunty which requimaperm(t to constact,ilier,(mprove,demolish,or repair
Y anystm=mprlortoib Lssuamealnrequimtheapplfoantforsuch PenellPOWER DEVICES
y file a signed statement that he la bl
licensed pursuant to the provons of the
OLL� Conmictor'sLicense Law(Chapter 9(commending with Section 70(0)of Divi- SWIMMING POOL ELECTRIC
'30 sion3 ofthe Busineuand ProfessionsCode)arthat he b exempt therefromand VALUATION
Set 5 the base;for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHFSFDTURES �j-vD
p
applicant permit subjecerfleapplidottoa civil penalty clout morethan 4Q�
�R - a'v ndred dollar(5500). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCTION
LS-�n I,u owner of the property,or my employees with wage a then sole
Z rwtion,wiNdothe work,and thestructureb not intended or offeradfor
O .]a(See.7034,Buslwsand Prolamines Code:The Contractors License Law
does not apply to an owner d property who builds or improves thereon,and OCC.GROUIs RFS.UNITS
u.$^ who doessurh work himself or through hiauwn employees,provided that such
improvements are,not Intended reoffered for We.If,however,thebuilding or TOTAL: ,uD
improvement issold within oneyearofcompletiogtheowner-wfiderwlll have
tl)tpurdenof provingmat he did not wild orimprove for purposeorsale.). CITY: ::°,�,"; PLUMBING PERMIT,"':-`'..-
i �:. FEP'< FT.00D ZONE AIN
L L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contraden to coatrud the project(Sec.70K Busi o s and Profesioa Code:
Ile Cimmoorrs License Law don not apply to an owner of property who
Wilds or fmproves themon,and who conram tfee such ptojem with a ALTER-DRAIN -WATER(FA)
aiRS, da(il loomed pursuant to the Conlnctoi License Law. BACK FLOW PROTECT.DEVICE " .FEE'SUMMARY
LJ I am exempt under Sec 17&P C for this reasonOUTSIDE FEES
Owner. e - -� DRAINS FLOOR ROOF,AREA,CONEL SANITARYRECFIleI'N
WORKMAN COMPENSATION DE(�I.ARATION FIXTURE,PER SCI400L TAX Y N
I F11I hereby affirm that I have a certificate of consent to sea self-insure,or RECEIPT N
certificate ofWorkers'Compernation Imumom ora certlfled copythenvf(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
. . Mill Lab C.) RFSFR'TX
ComffEy GASEA.SYSTFM-0VER4(FA) BUILDING DIVISION FEES
Certffmd copy is hereby fumbled. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified mpy b filed with the city trupedion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20037. Date Recef f#
(This sedion need not be completed if the permit efor one hundred dollars
(SIM)mles.) WA=HFATFRW/VENT/MFCTR ENERGY FEE Y_ N_
1certJythatlathepedrmunmofthewokforwWchthispem tisbs ,
I shall not employ any person in any manner an u to become subject to the WATER SYSTEM/TREATING
Woken Compensation Laws of California.Date PAID
7 Applicant Date Rcaei t#
Z PP NEW RESIDENTIAL PLMB. SQFT.
z NOTICETO APPLICANT:e, ftar thisCertificatc of Ctionpois Exemption,you
� should become subMctm the Worker'Compensation provisions of the Labor TOTAL:
Ytl1 Code,you must forthwith comply with such provisions orthis permit shall be BUILDING LLJ �f7
> deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 0
10 thereby affirm that there is a construction lending agency for the pedormTOTAL: ELECTRIC FEE • U
Z. aendersework for which this permit is Waved bee 3097,CIv.C.) PLUMBING FEE
J D Landers Name -
� QT
Ionone'sAaare=s Y:Y MECHANICAL PERMIT FEE MECHANICAL FEE
7 W omet. tagreet comply with
aRatiandcounyordiheawve in stateIion
u coract.logo to comply with allcityand countyrNinanasand rtatelaws PFRMTTISSUANCE FEES PAID:
Nrelating to building constmdion,and hereby authorize representatives of this
city to enter upon the above-mentioned W
- entioned property for pMion purposes. ALTERORADDTOMECH.
(We)agree to anve,indemnify and keep hermiess the City m CurpertlnDate RCCeI t#
Z
..I againstlf bilities,pdgments,masandexpenxswhichmayinanywayaame AIR HANDLING UNIT(TO I0,000CFhp SUBTOTAL: S
a�gm t said C",connque f the granting M Bus Permits. 1
�n1 AIR HANDLING LRsTf(OVER t0.000CFN) CONSTRUCTION TAX
d —� CONSTRUCTION TAX PAID:
igat a ntrador � Date 1 D(7-IAI)ST HOOD(W/DUCT)
HAlEARDOUS MATERIALS U CLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,(X0 BTU) Date Reaei t#
material as defined by the Cupertino Municipal Code,Chapter 9.I$and the
tiezlthandSf&y Crae,dirn2S532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL: f3S' 6
❑ Yes r!No
Will the applicant or future Wilding occupant use equipmem or devices VENTILATIONFAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous alt contamiants as defend by the Bay Area Air PARS
�-Tra'7lity Maagement District? BOILER-COMP DHP OR IMM])BTIh DoE/
I� ! 1 Yn n No .
y: lromm.elthehazar us materials rcqulrcrnunts under Chapter6.95 of BOILHR-COMP 100,000 BTU) APD
the California Health&Safety Code,Sections 25505,25533 and 25534. I APR f
understand that if the building don not currently have a tenant,that it o my NEW RESIDENfIALMECH. SQ.FT.
responsibility to notify the occupant of therequndrents which must be red n` .{ //ss,,,a
Prion.issuance.!.Certifidoeof Occepanry. V{y.of.VRSpV
I -fie.
Owner or authorized agent Date LReU"DRY:_V 7 U
TOTAL:
OFFICE COPY