21714 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Idendfkaeau L U+)—
Building Address:
PF3NITNO.
21714
rs ame: /- one:
�,
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT,
-
°Or
CATEGORY
CONIROLI
7y
/ BUMUN—ELF MCA PLUMBINGMECHAN'ICAL
nect/ neer.
/
/ (
'
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PEPMTISSUANCE
f�
LICENSED CONFRACEOR'S DECLARATION
Thembyafirmtktlamlicensed urderprovWmuofChapter9 (mmmm
IngwithStctbn7000)ofDv .3ofthe Butlnaaand Pmfe on.CM,and
APPLIANCESRESIUEDIAL
JOB DESCRTIIHON
Ikevt Is In fit lo7c! and effect.
Chr LI,, <
PANELSLilem
F-''"' ra��
Date '
Date Or
� ! D W
I01-1000
ARCHITECTS DECLARATION
!undersand mypUmshallbeueed as publlctecords. -
OVER1000AMPS -
SQ. FT. FLOOR AREA
S/SQ.FT.
SIGNS ELECTRICAL
Lkcm n! Prafembnal
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby afRrrn that l am exempt from the Contractor's License Law for the/��
f ntywhichrn.l$ ape (BIS,Buslnera er,imp bmeMH3kotltyor
countywech requbo alter, improve, demolish, or
TEMP. METER OR POLE INST.
its e,mmwct,
any structure tateprieolbbuarce, licensedlmtkat to the ooviioforsucia sa t e
mit to
file a abed statement that k b licensed Pursuant to the pcovbbnu of the
po,ER
'
�
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
ebn3ofthe Bu.ins m
and Pfessbru Code) or that he b meopt therefromard
VALUATION
the hub for the alleged exemption. Any A latba of Section 701 by any
appliant for a permit abjects the applicant to a dwil penalty cfnot mmethan
OfIII.EIS9WITCHI%.0 I V a
O
NEWR ENTI
fWe 1, ase dollars ofthe,pro with wages rheic dole
I,asowrcrll theproperty,a,orhe emrum
TYPE CONSTRUCTION
work, and Is r for
mm(See.
ctun b vet Intended or offerons,
7 K Business
dab (Sec 7044, Ba,lr� and rrdmbv Cade The eormaaord sande Law
hou C L
don not apply to so owner of pmperty who binds or Improve thereon, and
who d«aanchwerkhlmaelf orthrough hbownemplgaq provided that such
OCC.GROUP
RES. UNITS
Improvements are out intended oroffered f«We. If, however, thebulkdbgor
Impmvtment b.oW wnhlnorcyearof�snp letbn,tkowner-WBdrrwNhavt
t ndenofpcowingthakdwmtW9orimprm2f«purposeofsde.).
as owner of the property, am exclusively ntrxtlng with Licensed
U 4 m
contractor toren.truct the project (See, 7044, BwkesaM Prcaadcm Coder
TOTAL:
QTy, PLUMBING PERMIT FEE-
PERMITSiUANCE .
FLOOD ZONE
APN
The Contractors License Law does not apply to an owner of property who
build. or Imprwn thereon, and who comment for such p(ojects with a
c7➢tilactorW Bansed pursuant to the Contractor. Liana Law.
LJ I am exempt under Sec B t P C for this recon
ALTER -DRAIN& VENT- WATER (FA)
BACK FLAWPROTECT.DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, GOND.
FIX.NRES PER TRAP
SANITARY Y— N_
REC[IIal' N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby orkm the I have • losca are of consent to self-traure,ea ora
evnificatc of Workm'Compevalon lrsunna «a certlled copy thereof Etc.
3ROQ Lb C.)
SCf10DL TAX Y N
�p�, a
GAS F.A. SYSIT]d-1 INCA OUTLETS
PARK FEE Y N
1c N
CAS EA. SYSTEM.OVER4(FA)
Comm \ -r IaC.t G.(
DING DIN
BUILDING DIVISION FEES
ant
I I Cenlncd copy b heed with city
L��94•"-edined copy f. rlkd wnh tht city inspection alWalon.
GREASE/INDUSIRL WASTE INTERCEPOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF UEMPFION FROM WORKERS'
COMPENSATION INSURANCE
(1'Md section need na k cmnpleted n the pemdt b far oro hundred dollar
PAID
Date Recd tin
r-yJ
SEWFRSANITARY STORM EA 37QrE
tt1°cartlyth
I llnot employ anyhe Peron in any work so as to 1,tMa pemdtb boned,
L ork not empty any peas In any runner, at act to became subject to the
W«licant pewtbnlasvi al Gllfomla. Date
WATER BEATER W/VENT/ELECIR
ENERGY FEE Y N —
.
PAID
WATIR SYSI.FM/TRFA.DNG
rat
AppNOTICE
NOTICEoc APPLICANT: If, aftermaking tea atrtnloteo(Fi ofttbn,yw
Neildbecomefeth to the Worker' Comp rovisu pmvbbnofthe Lab or
Code, you rest fonhwnh comply with such provhbm orthb permit shall he
deemed rewakaa.
Date Recd tp
NEW RESIDENTIAL PLNB. SQ.FT.
TOTAL:
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyafirm that there b a construction lending agency for he perform.
sore of the work far whkh this PermX 3097, CIv. C)
TOTAL
ELECTRIC FEE
dboueci(See
Layette. Name �n
landee.Aaan,.
Icenlfythrtl have read thio app tbnand.tetethattheabovebdomm an
bcorrtct.I.gnatocomplywlthallcny.Mcountyotdinan dRatelaws
QrY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
D:
relating to building construction, and hereby autho ice o pnxntatNn of thio
vz
ro
city toenter upon the abovementbrcd property for Inspection purpose.
(Vie) agree b rvc, IMtmnly an d keep harmler the City oI Cupertlro
ALTERORADDIOMECH.
Date til
SUB'T'OTAL:
against llebWt4n,}idgmenu,aa.aM npense. whlrh wyln anywayamue
agairot.adC Inconrque«eo the gnntingdthlapermn.
y�cJ/
Ngnaturt al Appll�nt/Cant « Date
' IfA]ARIMU9MATER.A ISCLOSURE
AIR HANDLING UNIT (TO 10,000CFM)
AIR FUNDUNc uNIT rovF3l io,lnocFan
CONSTRUCTION TAX
FXHAUSp HOOD (W/DI1CD
CO $T UCTIOIy.Tj1X PAID:
Y 41 [7(/f
HFATING UNIT 17M 100,000 BTI!)
Will the appllont«future WOding pant store or handle h.ed.
makrl.l as deflnud by the Cupertino MuN pI CMq Chapter 9.l�and the
ate Recti IN
HEATING UNIT (OVER 10,000 BTU)
TOTAL:
Ele.lih andSafety CMe+_SHlon 7553]Wi
Rill1 No
«devices
whkheMt)a
Ienot, ppllant «Tran buildingamupant ubythe Bay
akrict? snbude0r iby lk Bay Ana Ab
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
BOILER -COMP PFB'OR 100,000 BTI!!
ernam
Illy hlavgemtnt District?
'have
b
❑No
*�..
�li('1�j�
BOILER-COMP(OVER 1W,000 BM
ve rad the lh Nwematerbls rtqumr,on,underChaper&9Sot
the C.W=UHeakh&Safety Coda Se l.r 25S(5,75533and2S534. I
N•ENRI9DENIIALMECH. SQn
understand that ifthe building don not currently have a tenant, that it is my
re,pmsOBly to notBy, the occupant a( the requImments which must be met
prior to Issuance of a Gertllhte ofOavpa1nry.
p
ISSUED BY:
Owner orauth agent Date
TOTAL.
OFFICE COPY