21412 (2) Hrr LNaFL1Y 1 iv FILL IPI IFar VTL1HMI twin ,ren a rses• nw ru��s.r — vv� aaes�a- a a_ae v,.r.
Building Project Identi(lollon PIRMrT NO.
Building Addmo: 21412
v 3 s ire. La 738- /3 P z—
s 'me: once A
C. 400n CITY OF CUPERTINO-BUILDING DIVISION 1 b—•Z �f2
co racto'sN.me: I Lie.No: APPLICATION /PERMIT
•._ C ' 1/s `t.'IT161Yv BUILDING-ELECTRICAI.PLUMBING-MSCI IAMCAL CAIECORY CONTROL
Archlieet afin eer. Lie.No:
QTY ELECTRIC PERMIT .r '• FEE BUILDING PERMIT.INFO
Address:• PERMITISSUANCE El ❑ LCJ� ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby Secti n7WOiron atl ivscm3.fthesed underprovisionssol Chapter 9(commmc- APPLIANCES 1 N
Incense 1,i 11on force andefelon3aflhe B(uIslnnsand Pro/msloneCode,and my n �•P,J{(/�
license bins farce and effect PANELS
T 9O L PANElS
License Class S_,I{`Contr 7 7 J
Uate rte'—z1 Contractor 201-1000 AMPS � �"i2��•
ARCHITECTSDECLARATION OVERIODOAMPS SQ.Fr.FLOOR AREA 5/ .FT.
Not0 1 understand my plans shall be used a public records.
&130 Licensed Profesalovl SIGNS ELECTRICAL
t1 OWNER-BUILDER DECLARATION
1A�Dg SPECNL CRCUIT/MISC
s- � Iherebyaf0mnthat lam eumptfrom the Contractor',License Law the '
following ream.(Section 701.5,Business and Pmfealana Code:Any city.,
F -^ countywhlchrequlresapermittowmtmd,alleplmpmve,dem Esh,errepalr TT7.IP.METEtO I 1�
q���ee a any structure prior to lis issuance,also requlrestheapplicaut fonuch permit toPOWER7WPOWER DEVICES
mi� \B
15 a w V file a signed statement that be Is licensed pursuant to the provisions of the —
Ow Contractors Lkevelaw(Chapler9(commencing wRh Sra1on 7000)of Divl- > l -'
COs sion 3 of the Business and Prefessi.nsCode)orthat he Is exempt therefromand SINQdh9NG Ii)O EL[GT'wd .✓ _ _ VALUATION
<5 the basisfor the alleged eaennietm. Any violation of SnclIm 7(X)1.5 by any OUTLETSSWITCIIES-FIXfURES �l
O
applicant for.permit subjects the applicant to a dell penalty d out more than Q
five hundred della.($5001. NEW RM AL r
7 F]L as owner of the properly,or my employees with wages as their sole SIO S TYPECONSIRUCTION
pensalon,will do the work,and the ewcture Is not Intended or offered for
5 O ce1e(Sm.7044,Businessend Professions Code:The Contractors License taw
(j $ dorsnotspplyt......er of property who builds.,Improves therem,nd OCC.CROUP RES.UNITS
E, whodorssuch work hlmxlforthrough hisownemployees,provided that such
Improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL:
Improvement dsold within oneyearofcompldion,theownerbullderwlll have
t rden.fpmvingthat he did not build or Improve for purpose of ssle.). QTY, PLUMBING PERMIT 'FEE FLOOD ZONE AIN
[_f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE !
comrade.to construct the project(See.7044,Business and Pm essmus Code:
The Contractor's License law does not apply to an owner of property who
Wild. or Improve thereon, and who cortmicL for such p(ojects with a ALTER-DRAIN&VENT-WATER(EA)
gq0a11(Tactor(.)licensed pumeant to the Contractor'+License Law. FEE SUMMARY
rLl I am exempt under Sec B &P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y_ N
—• Owner Date R—NI
WORKMAN COMPENSATION U[CLARATION 1'IXTURES PER TRAP SCT TOOL TAX Y_ N
❑I hereby affirm that I have o certificatea of consent to self-Insure.ora RECEIPT N
cemifiUb C.Workers CompevaU.n Wunnce.n certified copy themof 45ee CAS EA.SYSTEM-1 INCA OUTLETS PARK FIR Y N
DBW,lab CJ _
RECEIPT N
I'oliry N CAS G.SYSIUI-0V ER�(EA)
Cr, n4, BUILDING DI VISION Yr.ES
MCertified copy b heed with the
city CREASE/INDUSTRL WASTE INTQiCE'TOR PLANCIIECK FEE
Certified ropy b flied with the dry WpMl.n division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Dale RCCCI I#
(Phis section need not M completed If the permit b for ane hundred dollars
(sl Bfi)erlea3
Irertify that In the performance of the weak for which this permit Is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I shall not employ any peon In any manner so u to became subjrct to the ATER SYSTEM/TIT TING !
Workers Compensation law,of Callfomh
O Z Applicant NEW RESIDENTIAL PLMB. SQFf. Date ReLri t#
Z Q NOTICE TO APPLICANT:ILm
after,making this Certificate of Exeption,you
should become subject to the Workers Compemallon provisions of the Labor TOTAL:
CC Q1 Code,you most ion hwit h comply with such provisions or this permit shall be
deemed revoked. Bl11�QLN�,TE
W E3 CONSTRUCTION LENDING AGENCY _SEISMIC FEE
Dl I hereby affirm that there is a construction lend Ing agency for the perform, — —1 ELECTRIC FEE
Z aneedtheworki.,whichthbperMtI.,S e"(Sec3097,CIv.C.) TO
U O la•.drr.Name PLUMBING FEE
LL ~ Lende,r.Adderse QrY. MECHANICAL PERMIT FEE MECHANICAL FEE
l rectify than have ead this appliau.nand staethal theabove information
O W
0. acorrm.lageee to comply with all dry and county ordinance and state law, PERMIT ISSUANCE FEES PAID .
>. N relating to building constmctlon,and hereby authorize reprexn.Uves of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTOMECIT. Date RCCCI 1#
V — (We)agree to Live,Indemnify an d keep harMess the City of Cu pectin. F
agabatlhbNOes,jadgmenstaand.xpe. h{{Oi��c///hmuy1c.eywayaoaW
ue AIRRANDNGUNIT(TO10,00f)CFM) SUBTOTAL:
Cabuthe of perm
t said In con erou.
y AIR HANDLING UNIT(OVER I0,000CEM) CONSTRUCTION TAX
sI mbllapuam ons. r $� Dale rxIIA(Is'r nooD(w/Duch CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the appticsm or future building occupant store or handle hazardous I'[EATING UNIT(10 100,(1000TU) Date ReceI 1#
material as defied by the Cupertino Municipal Code,Chapter 9.1 7,and the - P
Ilcabhand Safety Code Sedlon25532(s)? IMATINGUMT(OVER100=11TU) TOT
Yea ON.
Will the applicant or future building oaepanl use equipment or device VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hanrdousair conlaminantsa defined bythe Bay Area Air —
•
Quality Management D❑istrict? BOILER-COMP(31B'OR 100,0(X)BTU)
4 Yes d No aL ' t7
have read the hen sue materials requirrmcnbundrr Chapler6.95of BOILER COMP(OVER 100,000 BN) P A
the Callfernia l lealth&Safety Code,Sections 25505,25533 and 25534. I
that notify
the occupant
ccu pant of tmrzenayhrv.+tenant.that b iset NEW RESIDENTIAL h1I!G I. AFI'.
responsibilityr toIssuance
of aCeheiate focup.therequlrcmenb which must be mel APR C
prior to issuance of a Certificate of Ocapanq.
/ rrJ 114
Owner or authorired agent Date - ISSUED (I(
TOTAL: —
OFFICE COPY