21986 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmed lde.milksam - 'PERMIT NO.
Building Address: co 21986
L/V•vr� one: - A
CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Uc.No: APPLICATION /PERMIT . v IrL�O" 6
BUILDING-ELECTRICALPLUMBINC-MECII rMCAL CATEGORY CONT"-Z
Bea/Engi e a �D�l. (-lJ
2(` - BUILDING PERMIT INFO
Q1Y ELfiCTRIC PERMTC •'. „FEE'�� - -
Addre.e:3� CWWI" I)Q, • PERMITISSIIANCE .9. .CI I .•N V'.
tluii M=T
LICENSED CONTR—A 'SDE URATION JOB
' Thereby affirm tMtiam Bcensed under provisions olChap[er9(mmmen APPLIANCFSRESIDENfIAL � ,,((J� OB DISC
Ingwith Sc ion7000)of DlAslon3o(theBusimmand ProfeWonsCcal my d�F�G, JOB
(a�fh(77
Ilttnss ie In full! and died. PANES 0`� ISL. �d
Llrensc Cly+ on
or
Date N—_Contractor
1 ARCHITECT'S DECLARATION 201-1000 AMPS
qQ2 [understand my pkv aMBbe uxdsspublic ncmds OVER 10D0AM1'S S4.FTOORP�i`EA $/S4.FC.
O -75 Licensed Professional 2- SIGNS ELECTRICAL 'l.
<Q OWNERBUILDER DECLARATION 7 SPECIAL CCRCUIT/MISC
I hereby afOmnthatlam e exam fromlhe Contractor's License law for the 2
ZO �, following reason.(Seaton 70211.5,Business and Professions Code:Any city or
couTEMP.METER ORPOLE INST.
p I-' ntywhichrequirnaper ttommtmdalteglmpmvemo
,deliah,ormpalr -
anysbb
ucture prlorto its nexuance,aonquima the applicant for such Fermat.
Ha. file a signed statement that M b licensed pursuant to the provblom of the POWER DEVICES
Contnao/s License Law(Chaptsr9(mmmeneingwlth Section 700)of Divi- SWIMMING POOL ELECTRIC
SOS sion3ofthe Budnemand PmfemiamCode)orthat hebexemptthsmfroo�Pd �n_�n� �� ALUATIC/
the basis for the alleged exemption. Any violation of Seaton 70X5 b�any F, 'S 'Oi `�
65 applicant for a permit subjects the applicant to a civil penalty of not mom Mn r�"'-
a. Five hundred dollars(5500). a NEW RESIDEtVTf L L FT. 'S'IOI2IFi TYPE CONS'CRUCTION
❑I,as owner.f the property,or my employee.with wages as their sok _ L
�7.Q compensation,willdothe work and thestmaure b not Intended at offered for � L V
ZO rile(Sec 7014,BueNess and Profesal.ru Code:TM Contnctore Littree Taw
k§ does not apply to an ownerol property who builcia orlmpravestMnon,and C ATEI
c, whodoea.uchworkhimseQorlhrwgh M1leownemplayees,provided that ch OC ' IIP NES.UNITS
improvemonls are not intended oroffered for sale.If,however,thebulldl a7, •�•�
Improvement bsold within oneyearofcompletion,theowner-buRderwlll have t I[C
ite�iurden of provingthat he did not build or improve for purpose of sale.), 4TYa : PLUMBING PERMIT FEE DZANE
u L as owner of the property,am exclusively contracting with licensed I PERMIT ISSUANCE r'1
contractco
ors to rutmct the project(Sec.7044,Business and Professions Code: 4 C.�
- The Contractors License Law does not apply to an owner of property who �•�-DRAW kVENT-WATER(EA)
! Wilds or Improves thenen,and who contends for such pRojean with a m ,
co,,IltR[CCactor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE M
LJ 1 am exempt under Sec. B k wn
P C for this rea
DRAINS FLOOR ROOF,AREA,GOND. SAMTANY- Y
q E4
Owner Date RECEPN—
❑ as
by ORKMAN COMP aTJSATION DECLARATION �.�S PER TRAP `� SCI{OOL TAX Y_ N
I Fereaffirm that I have s certificate of consent to uB-inmrc,ora RECEIPT N
r Ai(inteofworken'Compen tionlwuranmorattrtaladeopythereaff5ee. GAS EA.SYSCEM-1 INGd OI11LBI5
3800,Tab C.) 2 (O PARRFEE Y N
Policy p GAS G.SYSTEM-OVER 4(EA) REC=N
Com BUILDING DI VISION FEES
Certified copy hereby furnished. GREASC/INDUSTRL WASE INTERCEPTOR PLANCI-]ECIC FEE
❑Certified copy b filed with the city inspection division. ��6
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM SANRARYSTORM EA 200FT Date Rece1 t#
CThbuctlon need not M completed](the permit b forone hundred dollen
($100)IremilyWATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_ /OS—.IO
Icertlf th that in the rfornunce of the work(orwNch this permit le issued,
I shall not employ any person In any manner ao eB to became subject to Ne
Workera'Compenaatlon laws o(GWATER SYSTEM/TREATING
iltornla.Date PAID '
O Z Applicant NEW RESIDENTIAL PLMB. SQ.IT. Date Remi t#
Z O NOTICE TO APPLICANT:U,after making thin Certificate of Exemption,you
should bemnn subject to the Workers'Comperuation provisions afthe Labor TOTAL: 00.43
N Cade,you must forthwith comply with such provlslom mthis permit rhallbe •mss a^[ _ �.�jp
Uj > deemed revoked, B NG
el D
dC , CONSTRUCTION LENDING AGENCY SEISMIC FEE a to
I hereby affirm that then is.mmtmction lendingagencyfortheperfarm mELECTRIC FEE
7 Z an.of the work for which thin pert is Issued(5ec,3097,Civ.C.) TOTAL:
O O Lender'.Name - PLUMBING FEE
IL H Mnaerandarc.a CITY. MECHANICAL PERMIT FEE MSCI fAMCAL FEG
OWlcedifythatlhavereadthbapplicadonand Y.tethaatheaboveinformation
S bmrred.I agmvto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
rom
N relating to building nstction,and herebyauthorize representatives ofthla
F Z citytoenterupon the abovcmentionsd property for inspection purposes. ALTER OR ADD TO MECH. Date Recei t#
— (We)agree to save,Indemnify an d keep harmless the City of Gu pert Ino P
against liabilities, cosh and expenses which may lnanywayaceme AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
aga�l^�9saidC nconsequen f the granting athla pe it. /
LSI s _ res 9 9� AIR HANDLING UNIT(OVER 1g000CFM) CONSTRUCTION TAX
Signature, Applicant/Contractor / ale FX}Ip115'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle hazardous t HEATING UNIT(TO 100,000 BTU) sC� Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Fkalth and Safety Code Seaton 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL'
r7 Yes t]No
Will the applicant or future building occupant use equipment or devices VENTILATION IAN(SINGLE RESID) `� ISSUANCE DATE
which emit hazardousair carbur nano a.de0ned by the Bay Area Air
Quality Management DI�lsMct2 BOILER-CAMP OH?OR 100,0(10 BTU)
4havernia Healthe h
Soles Code,Se rcons BSM,
S ,25533ta and 255r8.95 of BORER-COMP 100,000 BTU) RV
the California Health kSafety Code,not
have a Sand,that. 1 � +
understand that If thenotify
the ing occupant of
a requiyhaves which
that Rbmy NEW RESIDENTIAL hiEQ{. �,FT. A�� 1
prior to issuelity to notify the occupant of the requirements whkh rrmsa M ossa
prior to issuance of a C,ertllicate o(Ocxvpanry. '
Owner or authorized agentV.1 v"O
Dat° ISSUED BY:
TOTAL:
OFFICE COPY