21032APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: )
�a88� S .'F�.blsay AVS• , Gs�4�R^t+No
PERMIT NO.
21032
where ams: one:
p�LtM G. Maw =--49"
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION I PERMIT
APPLICA nON SUBMIL IAL
C?'
— +�
Contractor's Name: Lie. No:
-
BUILDINC ELECTRICA PLUMBING-MFCHAMCAL
CATEGORY
CONTROL #
ArcMtect/Engineer. Lk. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE ��
❑ IC7� •❑ j� '-
XJ 'f-1
LICENSED CONTRACTOR'S DECLARATION -
Ihereby affirm that I am licensed under provisions of Chapter 9(mmmenc-
inerse 1 Section force a d diedn3 olthe Businesaand Profeeslons Code, and my
limns) le in tion 7000) and effect
License Class ` Lic.#
Date - Contractor
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION ,
1R/C��' 31-0K7L
PANELS
261 -IOW AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
OVER I WO AMPS
SQ. FT. FLOOR AREA
f/SQ. FT.
SIGNS ELECTRICA
Licensed Professiorat
OWNER -BUILDER DECLARATION
I herebyaffrrmthat I am exempt from the Contracture License Taw for the
SPECTA IRCUIT/
following reason. (section 7031.5, Business and Professions Code: Any city or
=ntywhichrequiresapermitwcomt d,altegbnpmve,demolbh,orrepair
TEMP.M O INS
any structure deterrents that
(Ile a signed statement that Fa Is licensed pursuant to the provisions of the
he I, also sed Pursuant t the provisionsof the
Contractors License Law (Chapter 9(romrRncing with Section 7000) of Divi-
sion3ofthe Businessand Professions Code) orlhat he is exempttherefromand
POWER D S
SWIMMING LELECT C
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora perrott subject the applicant to a civil penalty of nat more than
OUTLE FIXTURES
NEW RESIDENTIAL ELECTR SQXT.
five cited dollars (550N.
I a owner o(the property, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
l O '
1 + c
pensatloo, w111dothe work, andthestructure Is not intended or offered for
c le (Sec. 7094, Business and Professions Code: The CmArectofa License Law
'
neat not apply to an owner of property who Wilds or Improves thereon, and
does ouch work hiev elf orthrough his own employees, provided that such
OCC. GROUP
RFS. UNITS
improvements are not intended orof(ered intake. If, however, thebuilding or
Improvements soldwithinoneyearo(completiorythe owner-budderwlll have
TOTAL:
tl�urden of proving that he did not Wild or lnprove for purpose of sale.),
u S as owner of the property, am exclusively contracting with u1n. d
contractors to construct the pmj)ct (Sec. 7044, Business and Professors Code:
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contracture License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojeaa with a
og0tjaclor(s) housed pursuant to the Contractor')License Law.
LII am exempt under Sec. B & P C for this reawnOUTS
ALTER -DRAIN & VEM-WATER (EA)
FEE SUMMARY
RACY FLOW PROTECT. DEVICE
I DE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT #
Owner Date
WORKMANCOMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of ale Alf m py tnemof or a
certificate o(Workeri Compensatlonlrsunnce ora certl(kd ropy thereof (Sec.
3800, Lab QGAS
�.���.�P
SCHOOL TAX Y_ N_
RECEIPT #
FA. SYSTEM -1 INCA OUMETS
PARK FEE Y N
Poliq #
RECE#
.
GAS -E1. SYSTEM -OVER 4 (EA)
Cam any -
DING I
BUILDING DIV] FEES
ffCe'filed copy is hereby furnished.
El Certified mpy Is filed with the city inspection division.
CREASE/INDUSCRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEM PTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200Ff.
COMPENSATION INSURANCE
Thissectlon need not be completed ifthe permit Is(orone hundred dollars
Date Re i t#
WATER [gEATFR W/VENT/ELECTR
ENERGY FEE Y N
PAIDAppli
(s1W)nrlese.)
I cema
rtifythat in the performance of the wok forwhich this permit is issued,
I shall not employ any person in any manner so as to become subject to the
Workers' Compensation Lawsof California. Date
WATER gySTEM/TREATING
ant
NOTICE
NOTICE co APPLICANT: e Work mating thio Certltlote o(lixemptlon, you
shmldbecomesubject tothe Lab or
offsuch
Date Remi t#
NEW RESIDENTIAL PLMB. SQ.Ff.
TOTAL:
orchis pofthe
Codgyou plywitorkers'
provisions
volud.forthwith comply with each provIslens orlhIs permit shall he
deemed revoked.
BUILDING' EE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihereby afflrrethat there Is a construction lending agency forthe perform
ance of the work for which this permit Is Issued (Sec. 3097, Civ. G
'Lender's Name
Lred)rs Address
I certifythatl havereadthis application and galelhattheabova Information
is correct.I a gree to comply with all city and munty ordinances and state laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
Z,C10
1
PERMIT ISSUANCE `Z•(:V
FEES PAID: ,
reettegtobutl mrotruction, and hereby authorize representatives of this
city to en pont above-mentioned property for Inspection purposes.
(We) agree to eve, indemnify an d keep harmless the City of Cupertino
against habil tl 'rdgments, rolls and expenses which nay In anyway arrive
aOinst said n n uence of the granting of this permit.
+y`(J6
`Datata ll
ALTEROR ADD TO M)iC}f.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIRHANDLING UNIT (OVER 10,000CPM)
CONSTRUCTION TAX
Skrmo rt/Contractor
EXHALE'I HOOD(W/DUCO
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date ReCei t#
Will the applicant or(uture building occupant store or handle hazardous
materlalasdefined by the Cupertino Municipal Code, Chapter 9.12, and the
I lealth and Safety Cctton 25532(a)7
❑ Yes No
HEATING UNIT (OVER IW,000 BTU)
TOTAL:
,Qi
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
fit
Wlllthe applicant o ft re, building occupant use equipment or devices
which eMthaza rd0us as defined by the Bay Area Air
Quality Management Dist 7
4Yes
'
BOILER-COMP(3FIPORIW,000BTU)
BOILER-COMP(OVER100,000 BTU)
hkvereadthehaza ous nulerials requiremcnta under Chapter 6.95 of
the California Health Safety Code, Sections 2550.5,25533 and 25534. 1
understand building does not mmartly have a tenant, that it Is my
responsi ityton 'theompant o(the regal to which must be rnet
p to an ofgcm sJ�
J'4
city ot
t
ISSUEDBY '
NEW RESIDENTIAL MECH, SQ.FT.
` �J Q
s ` 06
her or so t Date
TOTAL: t0
OFFICE COPY