21749 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
11.11clIM Projed IdentlfkaBw U- \ PERMIT NO.
Building Addrev(:�
1 \ pqL, \jO1.0
Jb "\ . C.01Q.,'7_ V)LNt� ` l`r� 21
749
Pheme.
APPLICATE5V3[M9nTAU=
CITY OF CUPERTINO-BUILDING DIVISION _
APPLICATION / PERMIT 1 Z— C
BI1N)INGELDCTRICALIIUMBINGM HANICAL �TEGORY CONTROL N
S Arch «x/Engtwer. Lie.Na
x t_
QTY ELECTRICPERMIT FEE �B/UILDING PERMIT INFO
Add. LICENSED
[2, 1,I-
LICENSED CONTRACTORS DECLARATION u
Py
Iherebya .70that famlbenaedunder
..ndeofCh .0(m and My APPLIANCFSRI9DENTIAL JOB RIPITON
Ingwlth5efIzIlI100)o(peffe,t (NeButl�and Pro(mYoruCode,and
LI oe xlcla:of NdLI 0,4301)cc-r rANEvs
Date c muradnr F -
ARCHREC'SDECLARATION '1000 AMPS
$2$�� IurdentaM rtry plan shall be used as public moords. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
rj Lf¢med Prdambnl 9GN5 ELFLTRICAL \ q S i,o
Q OWINER-BUILDER DECLARATION 1
Ihereby afOrmthat I sm.xempt from the Cordradorbbe
Lne Law for the SI>ECULCIRCIIIT/MI9C
p qq (olbwingrtason.(Sedlm70f1S,BualnewandProfeabnCode:Mytltyor44 4
F,7 u{ munrywhld¢quUes m
a Permit tomtruM alter,Improve,demolish,ormpalr TFMP.MEIFR OR POLE
5 X77any.tuG mprbrtoltsfam..,. ornq.r theappUontf«auchpr to pOWFR DEVICESRle a slimed statement thehe b Bmnaed pursuant to the prodslon of Ne
gnone
Ctrsotm.Licenslaw(Chapter 9(mrunor ng with ScNUoo 700))of Divi- SWIMMING POOL ELECTRIC VALUATION
FNon 3 of the Bu slum and Profimbn Code)or that he is thrdlromard
s the baab for the alleged exemption. Any AWatbdb
n of Sen 70715 by any I'
60 applicant fora perMt subjnasthe appBrant toa ddl penaBydnot nndtlun OVILEISSWITCHESFUCNRES \ 5 42 q
five mired dollars%5M.
dI as owner of the property,or my employees with wages as their sole NEW RESEDENTIAL ELECIR SQFI'. STORIES TYRECONSTRUCTION
k%< aadon,wllldothe work,aatrutludbmt WedMorcd for
�+..❑ sale&c 70LuPrdesxxmn Cade:The C.waaorW LIexrxix I,.w
P;F$ does wt apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
y who does°uchwor4hlmelforthrwgh hbownemplq¢s,provided that such
ImprovemeMead vot Intended oroflertdf«sale.IL h«vever,the building« s TOTAL
4 pmvem ratio l hinomyearofcompletbn,thewvner-builderw UBh
rden.fpm"tIvdhsd1d mtbuildorbmin .2forp„rposeoraale.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively coems,ung with lxoxm ed ELOOD ZDNE APN
.h.tod to mrutrunt the proJed(Sec 70K Busiure and Prdesbru Cade. PERMIT ISSUANCE
The Contriaorb License Taw does not apply to an owner d property who ALTER-DRAIN k WATER @N
Wilds or Imu prwthereon,and who cenddtls f«such P(ojeeb with a
q➢Irac.r(.)Bce a pmranant to the C«dradwa Lii.Law. mac FEE SUMMARY
LJ I am exempt under Sec B to P C ler this reason QUIrg'DE RES
Owner Dns A $ SANITARY Y N_
RECEIPT a
WORKMAN COMP04SATION DECLARATION SCHOOL TAX Y IN
❑[hereby affirm that I haw a¢rb/lote of consent to self-Inane,or a
¢AIRWeot WorE Comperuatia Il an¢«a¢dlfledaopythertof(Sec. CAS E1. INCtOUIT.EIS PARK FEE Y N
3800,1.bC.)
Pdhy r Is RD_FReI e
Com nv . ��.F•V GAS FA'SYS[ BUILDING DIVISION FEES
ErMif[ CCedlfled copy is hrrebyfhMahed. GREASE/INDUSIRL WASTE DnERCEPTOR PLANCHECK FEE
led copy is filed with the city Inspection dfvblm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREMM TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYF LXEI Date ReCYI (# 1S.$O
(I1ds Wedbn need w he completed lithe pemdt b f«one hundred doBan
(fT
00)or WATER HEATER W/VENT/FIFCIR ENERGY FEE Y N
I anoy that M the pe.In sof tmanne,f.rwto h thio pemdt b booed,
1 Whin not employ any person b any manner m u to bceome subject to the
WATER SYSI17d/TREATING
w«..n compena.tbn law..f Gluomla.Dae PAID
0 Z Appliont NEIV RESIDFNIIAL PLMB. SQFI. Date RCroet t#
Z NOUCR TO APPLICANT:If,ager making t his Cedlf"m of Exemptbn,yw .
N
should becorne subFctbthe WorE.n'Comperuatbn pmvbbn of the G r TOTAL:
a. Code.you mart forthwith comply with surh provisions.,this permit hall be 163 L.00
LU > d¢nxd revoked. BUR DING FEE
CONSTRIICTIONLENDINGAGMCY SEISMIC FEE tu.65
a Z hercbyaffirm ttF mbamntmWRmle bgagencyforthepedonr, TOTAL- ELECTRIC FEE bQ.cn
anm of thrw.h for whkh thio pc,pd isbsued(Src3097,CN.CJ
V O Le'nder's Nam l l h PLUMBING FEE b0,c,O
LL F Iendre.AddleeeQTY. MECHANICAL PERMIT FEE
MECHANICAL FEB V u.c(u
O W Irmo..lag l we mad rnplyw ha tan nn"rdtheabov dwat udm ���
D. bmingt Wil,fitormenruwhh andtyaM muntyordbunaetattl elawe IaF]tMITI55UANCE
} N
relating oenterupongmnWrudlon,and hereby Pty orlaercproentaBvn ofehb
H Z
dry agree
to saw,
inve-mntbn it property for Wpe Cit purpose. ALTF]20R ADD TO AEKI-L Date Recel t#
- (We)°gree to sw,Indemdfy an it keep,h whish the City o/Cupertino
ag.Wtllald City).consge,matsard expenaa which mylnsnywayamue AIR HANDLING UNIT(f0l0,OW CFAs SUBTOTAL:
agawtsldChy lnconsequence.f the girding alibi.permit AIRHANDWNG UNIT(OVER I0,000CFM) CONSI'RUCIION TAX
c .a I� ��.w 1ti- ,
Signaure of ph.t/Contract DaTte E( USIHOOD(W/DUCT) CONSTf2U(�OI�TAX PAID-
HAZARDOUS
f11 D:
HAZARDOUS MATERIALS UISCLO RE /T�_-'E-LV{7 _ (�Jx(LdC-��esL
WBlthe apphant or future building occupant atone or handle havrdoue HEATING UNBT CM IOg000 BTU)
mDate Recel [#
iedal as dcflu�d by the Cupertino Murddpal Code,Chapter 9.I Z and the
F .hh and SafetyCoda Sedim _ ING 25532(.)? HEATUNIT(OVER IW,"BTU) TOTAL:
ap
qui
No
Bl thepllum« tort WJigoov l.t..N.1pmntordevlm VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harandou.ab�xxetaMrarus ae defined by the Bay Area Air
Quality Management Dist red? BOILER-COMP PHP OR 100,00D BM
4hYo N. Fes
aWemathrh sorter"requiremnb under Chapter G9i or BO LGR COMP(OVER100,000BM { �QQ
the California Health h Safety Ccdr,Sect bra 25505,roS33 and 25536.1 14 X 91
a rad enela netthat if the building does not mmently lave a tenant,that it is my NEWRF9DENTIALME(H. SQF7
rsponbBBy to not By the«cupant of the requirements whRh rust be met
prim to Lwua oce d a Cenlfbste of 0,u pa my. laoFry1.a',w
C.. .( ' Mr,1\xaw 1�Lti1
Owner or auth" agent Date ISSUEDBY:
TOTAL
OFFICE COPY