21686 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Nulldina Prided Identification ' PERMIT NO,
Build ing Address:
..� , /7�& 14ll'or�ar' 21686
i arsv.e,eisms, .Mons: -
- g CITY OF CUPERTINO-BUILDING DIVISION wrruutwN aunmutA��wte
�ontractor'e ame: LIc.No: APPLICATION / PERMIT 22 I��
ItM/Engineer. s Lk. o: BUILDING-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL#
)ji BUILDING PERMIT.INFO' r
ECTRICPERMIT',. ' 1;,1 „',.FEE,•' _I
Address: `�X PERMUISSUANCE �^'•''umn mu,n
LICENSED CONTRACTOR'S DECLARATION El Ihereby affirmtlut l amllemsed underprovislons of Chaprter9(comman4 APP11ANCES-RESIDENTIAL .JOB DESCRIPTION
_xingwith Senion7000)of Divielon3oftheBuinessand Prof ler.Code,andmyl
11 in Lic,lraMO �o� (III_- DP ozooAMPq
ARCHITECTS DECLARATION 1201-1"AMPS
wwwre 7O I understand my plans shall be used as public mands. OVER 1000 AMPS ]I i SQ.FT.FLOOR ARFA y/SQ.FT. '
�j Licensed Professional I SIGNS ELECTRICAL li ,
OWNER-BUILDER DECLARATION SPECIALCRtCUIT/MISC y
y T G Ihereby affirm that l am exempt from the Contractor'sLicense Law for th-
O H following mason.(Seaton 70715,Business and Protesid ..Cade:Any city or TEMP.METER OR POLE INST. I
F a cmntywhichrequi--peradtmconstmd,ai[eyU pmw dennllsh,orrepalr
anystsunvre priorto its iewance,also requires the applicant(or ouch permit to t
aa 0k a si ed rtaterrent that he h Ilcenesd POWER DEVICES
O a V 3r' pursuant to the pmaislom of the
Sion 3 of the License Business and Professtherefrom r
Professions Code) he IS exempt nd SWIMMING POOL ELECTRIC I 1
I] VALUATION
tot bash for the alleged exemption. Any violation of natty 70715 by any
Q^p five an a permit SUbjenathe applkanttoadvd penalty of not room than OUTLETSSW[TCHCSFIXTURES
n tv`
five hundred 1,as wner of the pr. NEW RESIDENTIAL ELECTR
.. �I,as Owner of the property,or my employees with wages as their sole l SQ.FL
I I STORIES TYPE CONSTRUCTION:
k,7a compensation,wllldothe work,and thestruentre limit Intended or offered fort I 11+ -
0 Sale(Sec 70K Business and Pendadiod,Code:The Contractors License La i
$$ does not apply to an owner of property who builds or improves therms,and L__I OCC:GROUP RIS.UNITS
who does such work himself ortheaigh his own employees,provided that such -- - -
Improvem enta are not intended oroffered(orsale.If,howl mr,the Wilding or TOTAL:I
Improvement is said with In one year ofcompletion,the owner-build er will'. '
trye�.,denwner Proving
of the property,am bond.,improve forpurposeofcaled. QTY.':"`',sl PLUMBING PERMIT 1 ' :I,' FLOODZONE APN
LI L as owner tr the property,am exclusively contracting with(sensed PERMIT ISSUANCE
The Co tr to construct the projects(Sec.
not apply Business and Professions Code:
The Contractors License Law does not appy ct an owner of property who ALTpE DRAIN&VENT WATER ffN
Wild. o Improve thereua and h who contracts im such project with a 1 i I
cgNfan rd"exemd' .d,,Set to the ContractorSLlceS P Law. BACK FLOWPROTECT.DEVICE I n' tFEEISUMMARY '
LJ I am exemp'under Sec B&P C for this reason
I � � (111T51)IF FFmi �
Owner Date DRAINS.FLOOR,ROOF,AREA,COND. I SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT
❑1 hereby affirm that I have a cerifiate of consent to self-Insure,or a I FTXTIIRE&PER TRAP I 15CHOOL TAX Y N-
or m''CompensationInsurancemacerti fiedmpythereof(Seel RFCEB'Tp
3800J.1,C) GAS-EA.SYSTEM-I INCAOUILET.S I (PARK F Y_ N
Policy Is EE r
C_Ca•• (GAS.EA.SYSTM-OVER 4(EA) I RECEI PT T X
Red copy h BUILDING DIVISION FEES�rt0ed ropy h filed With the city inspection division. CRFASEANDUSIRL WASTE INTERCEPTOR JiLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP I PAID
COMPENSATION
ot Wcom ATIONINSURANCE (SEWER-SANITARY-STORM EA.200FI. I' Date Recei t#
' QherSection need not be complMed lithe permit him one hundred dollars p
(St I medlyss.) WATER HEATER W/VENT/ELECTR I '.NERGYFEE Y N
I shall net employ o the peraiin in an the work an as tob co permit b earned, -
I Shall not employ any perun In any manner n ss to become object to the
Worken'Compensadon Laws of California. ATER SYSTEM/TREATING la.Date I (PAID .
C' Z Applies. .
Z O NOTICE TO APPLICANT:10fier making this Certificate of Exemption,you NIEW RESIDENTIAL PLMB.__SQFT. I 1I1 Date Receipt#
U) should bacteria,subject to the Woritas''Compenation provisions of the Labor I I TOTAL:
Cade,you must forthwith comply With such provisions or this permit shall be
- �
LU > deemed revoked. BUILDING pIiE
a C CONSTRUCTION LENDING AGENCY I I SEISMIC FEE -
I hereby affirm that them Is a construction lending agency for the perform, :LECTRIC FEE
0 ante of the workfo,whkh this permit IS issued(See,3097,Civ.C.) TOTAL:I'
O Lender.Name I .FEE'-- PLUMBINGFEE
LL U Lender's Address QTY. MECHANICAL'PERMIT;? MECHANICAL FEE' '°•d�AyaY./
O W Icect.Iareeto C ready With alcityndcuntyordl heabove ln(ormatlon I �gr
Is correct.legreeto comply with all city and muntyoNlnances end statelawsl ` I'ERMRISSUANCE II�'♦'J PEES PAID:
>- COO relatingtobulldingconstavMlon,and herebyauthmixe reprewntativeSo fthla
H Z city to enter upon the above-mentlomd property(or Ins purposes. I ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupert e., — Date Receipt#
O agalnstl bllitie.,judgrmnts,"sand expenses wh muylnanywayacauel AIR HANDLING UNIT(TO 10,000 GEM) I I SUBTOTAL:
agal of City lnronsequen f the gra peron /z'�l
AIRHANDLING UNIT(OVER10,00BCEM) I CONSTRUCTION TAX
tore.!Applicant/Co our Data IXHAUSTHOOD(W/DUCT) I (CONSTRUCTION TAX PAID:
HA US MATERIALS DI. RE
ilithe applicant or re building occupant store.,handle hardous I ( HEATING UNgT(TO 100,000 BTU) Q
Ieml as defnN by the Cupertino Municipal Code,Ch, a CD
pter9.12,andthe I /awl Date Receipt# ) � rte'
IIr❑althand Safety Codr,.5ectlon25532(a)7. I HEATING UNIT(OVER 100,000 BTU) I I TOTAL: i--L�7-0/ J
Yea ❑No
Willthe applicant mfutuse building occupant use equipment ordev ices VENTILATION FAN(SINGLE RESID) rpss ANCE DATE
r - which emit haturdous air contaminanxisi defined by the Bay Area Air
Quality Management District? I BOILFE-COMP(31HPOR100,0001HU)
((��Yea n❑No �
'`?hay.mad the baeS9LSmaterials requirements undtnChapm,6.95 of IBOMER-COMP(OVIR 100,000 BTU) JAN 02 •-199'�.i
the Cehfornla Health&Safety Code,Sections 75505,75533 and 755-14 I
understand that lithe building does not currently haven tens nr%"iris my NEW RESIDENTIAL MECFI. SQ.FT.
responsibility to notify the occupant of the requirements which=at be met 1�.asag(yam
prior to Issuance of a Certificate of Oceapanry. W Sasa�aW+11{el
Owner or authorlaed agent Date (ISSUED BY0.JN./--fib ✓
TO
OFFICE COPY