21649 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
build Ing Address; ,? 21649 OW
sere erre: one: A A
C1E,0211E LU4x 1-{I40 CITY OF CUPERTINO-BUILDING DIVISION
G°ntrA°era Name: LIc,N.: APPLICATION /PERMIT
Aa' Solm k BUILDING-ELECTRICALMUMBMG-MECHANICALCATEGORY CONTROL0
Architect/Englne r. Lie.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PER&ETISSUANCE ❑ 11 11LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter9(commenc APPLIANCESRESIDENML JOB DESCRIPTION
I.enseISection forceA dAffeon3.(the Buelneafand ProlculonsCadeand my
Manx lCLass force and effect. PANUS
Llanx Clara LiLN
Date Contndor UP TO 2DOAMPS
ARCHITECPS DECLARATION 201-1000AMPS
po?re0 7�5 I understand my plana shall be used as public rc.rde. OVER 1 WO AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
E 1(C� Licensed Pm1A.l..al SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SI'ECIALCIiCNT/ LSC
z f., 7, Iherebyafl.that l am exempt from the Contrzdoes License Law for the
K4Q !qqqy following reason.(Section 7071.5,Business and Professions Code:Any city or
°� ❑ countywhich requires.per dtto..0 d,.It.r,impmve,demolish,ormpair TPJ✓P OR LE INST.
❑ any,tmu mpr rtoibis ame,allomquimtheappR.ntf.r..chp.v tto
O [b D
file A signed statement that he h x
hand pursuant to the provisions of the
m
w Contractor's License Law(Chapter 9(commencing with Section 70))ofDivi.
30 Alon30fthe Business and Professloru Code)orthat hats exempt therefromand L CIRIC VALUATION
the bash for the alleged exemption. Any violation.f Section 7031.5 by any
G$ applicant fora permit aubjectsthe applicant to a civil penalty of not more thanN�w
five 1,as o d°Ihn(,M. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with waled as thele sole7for
Q compensation,Boston,.AndkandthesWtlurehnotlntecim'orcnseLawq sale(Sec.70Kpply to alnan owandf property Code:The Contractors LiceherseeLawdodnot epplyt rkho rorth pghhiso emplyilds,or i ,p vdihemryand
chOCC.GROUP RES UNITS
whodoeeeuchworkhlmxl(orthmughNsownemploym,providedthatmchimprovemen.arenotintendedorolferedforsale,Ilhoweverthebulldingor
improvement lasold within oneyearofcompletlon,the owner-W ilderwlll have
tIAllurden ofpming that he did not build or improve for purpose of sale.). PERM
QTy, PLUMBING IT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed IT ISSUANCE
..tract..to coma uct the project(Sec 7044,Business and Professlo s Code:
The C.ntredo's License Law don not apply to An owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilds or Improves thereon, and who contracts for such pr - -
ojects with a FEE SUMMARY
<gn7pcYor(a)Il.nsed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE
lJ 1 am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y N_
' Owner Date RECE[PI'N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
QI hereby affirm that I have o lmumn of consent to pythemof ora RECEIPT
N
a00,La sofWorkers'C°mperuatlanlnsuranceoracertllled.pythereof(Sec. GAS EA SYSTEM]INCAOUILETS PARK FEE Y_ N_
3BW,Lb C.)
Policy N RECEIPT N
Com Can GAS EA.SYS EM-OVER 4(EA)
YlOed copy BUILDING DIVISION FEES
ertla hereby furnished. GRRASE/INDUSrRL WASTE INTERCEPTORPLANCHECK FEE
Certified copy la filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' CRF-ASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM FA 200PT Date Retei t#
Ohhxdlan need not W completed](the perrtdt h!crone hundred dolls.
($l0bmIess) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I.rtlfythat In perfor na !the work( Ich tial pe Ithlaaed, —
ahall nm amp a y pend I ny manner a °.eco pct to the WA.I.Ot SVSIP.N/,IRFA,DNG
wmkeri cam es on saw Itfomla.Dal '1 PAID
O Z Applies
Z NOTICETO become ICA Qafier makinrs'Co t hC, npro icons of(he
eLyou
NEW RESIDENTIAL PLMB._SQ.PT. Date .Rees[ t#
sheAdCode, ou=st ubkctlothe Workers'Comp eowionpmvhlm permit slabs TOTAL:
a. (A deemed.un.Jmd. hwllh comply with such proWi.v or this permit shall be `
> domed revoked. BUIL12ING FEE
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency cribs perform- ELECTRIC FEE
M Z ance of the work for which this permit is issued(Sec.3097,CIv.C3 TOTAL:
V O Lender.Name PLUMBING FEE
LLh' Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW I artlythat l have mad this application and stanthatthe above inl.rmatlon
G incurred.I agree to complywllh all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>- N relatingtobulldingromtrudlon,and herebyauthorlae representativesof this
F Z city to enter upon the abovementlonM pmpartylepppactionprpteses. ALTER OR AUDIO MECH. Date Recei t#
e)a to save, !y an d keep ha the City of Cupertino
Aga Wt lobi todgme ., sand ex Pa.. ich yinany aya a AIR HANDLING UNIT(TO 10,0DO CFM) SUBTOTAL'
age Wtuld 1 into ue ofthegmrting° thl permit
AIR HANDLING UNIT(OVER 1Q000 CFM) CONSTRUCTION TAX
Signaturef ppRom .atra mr Date EXHAUST HOOD M/DUCO CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DIS OSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,0DO BTU)
material as defined by the Cupertino Munlclpa l Code,Chapter 9.1 2,and the Date Recei t#
Fleallh and Safety Code Section 25532(a)? HEATWG UNIT(OVER 100,000 BTU) TOTAL:
Yea E]No
Will the applicant or tutor,building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ]SSI / } TE
which emit hanrdous air roma miw cats as dented by the Bay Area Air
Oty Management District? BOILPR-COMP OHP OR 100,000 BTU)
Yrs n❑No
ahavc nadthehavMad ma ferialerequimmenhunderChapter6.95of BOILER.COMP(OVER IW,OW BTU)
the California Health 6:Safety Code,Sections 75505,25573 and 25534.1
understand that if the building don nod currently have a tenant,that it is my NEW RF5IDENTIAL MECH. SQ.Fr
mono bility tobalsas notify Certificate
of of the requirements which most be met Pt; ply .,rp
prior la hsuanre of i y the occupant
of Occupancy.
Owner or aulhotised agent Data TOTAL: V ISSUED BY�y(,—efP-3 MXk&
OFFICE COPY