21734 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.oWl.il Pruje Identification T- PERMIT NO.
Boilhdffig Address: 21734
\ CJ b'�4 W o0D\A I k..
oras. one.
CITY OF CUPERTINO-BUILDING DIVISION
Contractor'.Name: Lk,N¢ APPLICATION /PERMIT
BUf1.DING[]DCMCALPLUMBINGMFLFIAN'ICAL CAI RY C I,M
Arc ItM/Fsgln¢r. Lk.NIX
iG0"5:' Qry ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PQtMIT ISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION&ChON
I hereby SectIeffirmA70 that lam licensedoftheunder provtdonedpupter9(mmmm APPLIANCES-RESIDENTIAL )OB DESCRIPTION
ingwhh Sedbn 7000)al Dlvisimr 3otthe Butl.sandlarofnelon.Code,and my
L]ioms licensele In Class ( and effect. PANELS _
Date Gontnctor UP TO 200 AKFIS
ARCHITECTS DECLARATION n-1woAmps
otz IuMereard mypbrseusUbeuad epublicrtmrd.. OVERIODOAMPS SQ.FT.FLOOR AREA $/9Q.FT.
E 06 Licenscd Prof®bnal SIGNS ELECTRICAL
�-
1µ OWNER-BUILDER DECLARATION
Ihereby afRrmthat l am caempt from the Contractor'.License law f¢the SPFGIALCBiCNT/MLSC
pp following Mason.(Section 76715,Bush,led Profession,Code.My city or
C
6 z TEMP.METER OR POLE MST. p�2
K5 countywhh requ4 ape. wmM d,alter,impmve,dennlatkormpalr J V J
y anystrulurc prlarto 1, s
inunce,also requbesthe applicant f¢wch permit to POWER DEVICES
C Ble assigned statement that he is licensed pursuant to the provlsloro of the
Dµ Contractorb Llceveliw(Cfupter9(commencing with Section 7(I0B)of Divl-X
SWIMMING POOL ELECTRIC VALUATION 05 ebe3of tM1e Buelneuand Profembro Cede)ortM1at he Hei¢mptthertfromaed
!he halls for the alleged caemptbn. Any ,violation of Setlbn 70715 by any
�� appgontfora pemdt subjectstheappBcanttoa dull penaltydna morelhan OVfI"E'1""V.7'ICFIFSFlXNRES
fl hundred dollars MOD).
1,as owner of the Property,or my empbyen with wages u their sok NEW R®QJ7T'V'ELFITR SQFF. 19/�*D1
NSIRUCIiON
comperuation,wWdothework,andthestructure itomIntended oroffered for E vk�7DK Busiro.and Pntneiom Codr The CoMrador.W¢nse Lawdon rot apply to an owner d property who build.or Improves thereon,andwhodoowch workhbmelforthrvsgh Naownemployen,provkled that such
TOTALement bwMwithinomrarotcompIMt mtMo er-WBderwUhive J.r� n
tlitpurdcoofpmvingthn he did ontbuild orimprovefwpurposeofeale.). QTY. PLUMBING PERMIT
"I,as owner of the property,am exclusively cot... ,__B¢ved
contract.to mrotwct the project(Sec 70K Busineae and Prdeobro Code: PERMIT ISSUANCE
The Contractor.License Law dm not apply to an owner d property who ALTFTt DRAM 6 VENT-WATER(EA) -
buON or loop.thceon, and who contracts for such ptojed.with a
oa(f,ct¢(a)licensed I,...ttotbaContractor.Li¢r�Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U 1 am exempt under Sea B k P C for that recon
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N
Owner Date RECFRTR
WO0.m that ICOMPENSATION
ce, DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
❑f hereby shalom that 1 have a¢rtlO¢te d cont to self-Insurt,¢a RECEIPT If
31100,
LabdWorkers Compewtion lrouran¢¢a¢mBfed copy thereof(Sn. GAS EA.SYSfEAf-I INGa OUTLETS PARK FEE Y N
lvk a CJ
'aby GAS FA.SYSTEM-OVER g(EA) RING DI A
Co rt i )reb ht40 P� Frl BUILDING DI VISION FEES
CedNe!copy la herebytumecity GREASE/INDUSIRL WASTE INIFRCEPTOR PLANCHECK FEE
CcrtHled ropy Is,filed!with she tlty lropettbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWERSANIT'ARYSIORM EA 200FT Date Rccxf [M
(I'hlsaectbn need nae k
COMPENSATION
lithe SURA V!¢orae hundred dallan
($10D)or I..) WATER I-LFATER w/vExr/D.EcrR ENERGY FEE Y N
I¢rtlfythat Inthepedornun¢of New¢kforwW&thLpem i.b ed, —
I shall not employ any person In any manner an as to become subjed to the WATER SYSIFAIlIREATiNC
lVorkera'Compenutbn Tawaof CaWornla. Date PAID
NEW RESIDENTIAL PLMB. SOFT.
A Ilam
Z Q NOTICE oldbeOnst subCAM:If,aftereWork nuking this
sation¢teo(Enemptbn,you Date TA t}I
shmidou .forth itthe Workers'aomperu.tlmr or thisuofthe Labor TOTAL:.
� N demedrevlord.forthwith comply with suchprovlabroorthiopermit.Milk S
] deemed¢voiced. q0, D
CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
[L Iberebyarnrmthat there lsacoremotlon leadmgagency,for the perform. ELECTRIC FEE 3S
7 Z an¢oftheworkforwhkhthit p�mlt is issued(Sec-3W7,CIv.C.) TOTAL `7 J.
U enderaw¢ �� I n PLUMBING FEE
LL I- Lendcr.Addrtsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 70.35
O W I¢rtHythatl havercadthlsap Rcatbn.rd natethattheabove WormNlon
bcorua.l.greemcamply whha0dtyard county ord4uri¢sandrate Owe PERMIT ISSUANCE FEES PAID:
} N relating to building mnotruction,and hereby authadu opresentatives of this
F Z
city to enter upon the abovcmentbmd property for Inspection purposes. JALTERORADDTOMECTL DRIC Recei IN
(we)agrce to save,mdemNfy an d keep harmless the City of Cupertino
U agenst Babilitks,Judgments,m.la.ed e.Ixr.which may In anywayacvue AIR IiANDLINc t1NII'(ro 1D,000 ctM) SUBTOTAL: '
.gamut oro City Inren.7uerh¢of the granting of this pemdt.
C .
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX
' Slgnaturt of pg¢
Dte
IXHAUSTHOOD V/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERSCO URE
Will the applicantuse igoacupartHoeor handle ha d HEATING 100,000871)
Dmalas defnedlby the
rton,MurddipalCode,Chapter9.1;and the
Date ReI ti
Falth and Safety Code Stcfiw25532(a)7
IiFA77NG UNIT(OVER 10°,000 B7'ln TOTAL: 1505.0
quiI Yn []No
Bront applicant¢ tutenhubuilding arvpandby equipment ordevkxs VENTILATION FAN 751NCLE R737DI �S$LlA•(�CE DA'Z'E
which eMahanmou.airrict? ntsande/Irud by the Bay Area Ab
Quailty Management District? BOILER-COMP OER'DRIW,ODO
Yes ❑No 1991
have read the h.,9.us materials recprirements under Chapter 6.95 of BOILGWCOMP(OVER iD],000 BTU) rtB 14
the CalHomi.Elealth 6 Safety Coda Sections 75505,15513 and 2S5U.I
underslarcl that ifthebullding does not currently have.tenant,that it l.my NEWRESDFNTIALMECH. SQFI'
rnporomRlty to notify the occupant of the requlrementswhmh most he met C`
prim t.�hemance d�aaC..e,rtillcee dCI
IV
Occupcy. IV
�Jnhw 11L15 s
Avner or mash agent Dale
TOTAL: ISSUED6
OFFICE COPY