21308 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:
olio �aA f3yt/b. 21308
nere ante: one;
AL DA
:51__ ...T_O S flo#( ( L H- CITY OF CUPERTINO-BUILDING DIVISION
Coon�nstr�ac1�tor' Name: ^ Lk.No: APPLICATION /PERMIT - 1 o
UI D LL EC BUILDINGELMMCALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Arehitect/Engineer. Lie No:
Id RLE, QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Address: £ L(£_L-K� A-L�F_ PERM]TISSUANC11
LICENSED CONTRACTOR'S DECLARATION
m
I herebyaffirthat l am licensed under provisions of Chapter 9(emomenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Se on7OM)of DiviM=3o(the Buki and PmfnkonsCode,andmy -
Ilcense is m futiorm and effect. PANES
Llcee.zb —/ LICN f N639 ,pa.^I'T_ l
DatO Contractor erg f—Wraw/!TQ-FC,
ARCHITECTS DECLARATION 201.1000 AMPS
K OVER IOW AMPS SQ.Fr.FLOOR AREA $/SQ.FI.
tqqI��m O O I understand my pia shag be used w public records
k d L7mowtl Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
rid� SPECIAL GIRGUIT/M15C
z F., [hereby a(firmthatiam exempt(romthe Contractor's Lienee Law far the
p ❑ fol lowing mason. 7071.5,Business and Professions Cede:My city or
Fg county which requlresa permit to mnstmct,alter,Imm
peove,deollsh,orrepair TEMP.METER ORI OLE[NST.
a� a anysHvcture,pdorto Its Issuance,also requirestheappbant lorsuch permit to
FS w U file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
3u, Contractor.G License Law(Chapter commencihS
ngwltection7003lD
)olvi-
9( SWIMMING POOL ELECTRIC
e
on3o(the Buelnnsend ProfessloaCode)orthat he Isexampttherc(romand VALUATION
the baste for the alleged exemption. Any violation of Stolon 7031.5 by any UTLEISSWITCHESFIXTURES -OD
applicant for a permit subjeotsthe applicant to a civil penalty of not morethan
fiv., 1,as
ownerof thepro NEW RESIDENTIAL ELECTR SQ.FF. STORIES TYPE CONSTRUCTION
..�. u I,as owner of the property,or my employees is not with wage as[heir role
offered for
sompeneaHon,wlllncaa.ml Prof the etrude:TheCinta m'ed orcenseI .
sale(Sec. ppl to ani ow andf property
Code The lds orimpctm's Llceae law
E1j3$ don not apply imsero(p through
who Wlmporimproovidedvent mRuch OCC.GROUP RES UNITS
and
who doeasuchwork himsellorthrwgh hLownemplayen,provided that such ,
improvements are not Intended or offered for sale.](,however,the building orTOTAL: ed�
Improvement is sold within one yearo(completim,the owner-bunds..0.. ve
t4g-4uMen of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERM FEEF100D?DNE APN
u I as owner of the property,am exclusively contracting with licensed
mntrccton to construct the pmpd(Sec.7094,Buslnessand Pro(ewiors Code: PERMIT I SINCE
The Contractor's License Law don not apply to an owner of property who ALTER-D IMds VENT W (FAT
build, or Improve thereon,and who mntncta for such ptojecta with a FEE SUMMARY
�1t(actoRs)licensed pursuant to the Contractor's License Law. BACK W T.
LJ 1 am exempt under See. B&P C for this
recon
ORNNS P, ND. SANITARY Y N
Owner Date RECEIPT N WORKMAN COMPENSATION DECLARATION I�.NRES SCHOOLTAX Y N
❑I hereby affirm That I have•certificate of convent mself-Insure,or RECEIPT N
coldicate ofWorkeri Compensation Insurance or a certified ropy therm((Sec. GAS -1 .40 Ef5 PARKFM Y_ N_
3800.Lab C.7 PLa py�s.y RECEM
PolkyN Y ! J
CompanyC- Ta70 TV, BY 4�) BUILDING DIVISION FEES
CertHiedmpy bmi
htrebyfuahed. G /INDUSRiL A E'70R PLANCHECICFEE
Certified ropy la(Bed with the city lapectinn division.
CERTIFICATE OF EXE "1ON FROM WORKERS' G RTRAP PAID
COMPENSATION INSURANCE SETVPSSANITARV EA Date RCl%'1 t#
(Ihissecton need not be completed U ted permit Is f crone hundred dollars
($100)or edifyt.) WATER HFA V, /EECTR ENERGY FEE Y_ N_
n
I rtllythat In the perfarnunceolthe work forwNch Ihls permit Is Issued,
I shall out employ any person In any naniner m as,to become subject to the WATER SYSTEM T.RFA
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PfMB. SQFr. Date Recel t#
Z O NOTICE TO APPLICANT.If,after raking this Certificate of Exemption,you
should become subject to the Workers'Compematlon proisioa of the Labor I TOTAL:
09 Code,you moat forthwith comply with such provisions or this permit shall be BUILDING
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL M G Ihcrcby a(@mthmlchthis alructlon Isnding agency(or the perform ,TOTAL: ELECTRIC FEE OD
L) Z annofs Namkfor which this lslsand(Sec.3097,Civ.C.)
U O fender's Name PLUMBING FEE
h- Lender's Addres. - QTY. MECHANICAL PERMIT FEE
QW Inrtlfy that l have read this applimtbnand state that theaboveinformation MECHANICAL FEE
IL ismrma.I.gree to comply with all city and co.my.rdinarms and date laws PERMITISSUANCE FEES PAID:
>-
1" W city pO relating tobullding coawctlon,and hereby authorize reprceenbHvn o(1hIs
1 to entero .the above-mentiproperty ropeal'for Inspection purposes. AL7ERORADDTOMECH.
� Zf Cupert— (We)agree to save,Indemnify and keep harmiew the City of Cuino Date Receipt#
agaWtllabllltles,kmdgrirtnts,mob andexp neFswhlch mayloanywayacvue AIR HANDLING UMT(TO 10,000 CFM) SUBTOTAL: 0
a t maryl.sun a Oahe N
. M1gofth e 1 - CONSTRUCTION TAX
r QR HANDLING UMM)
UNIT 10,000 CI
St neo Appllont/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS ISCLOSURE
Ill theappilont orfumre budding occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cu penin:Municipal Code,Chapter 9.12,and the - s
Health and Safety Code ctlon 25532(.)7 HEATING UNIT(OVER IW,OW BTU) TOTAL: VV
0Y. . �SNo
WWtheapplicant oure building occupant use equipment or devices. VENTILATION FAN(SINGLE RESID) ISS ATE
which emit haurdous air contaminants as defined by the Bay Arca Air
Qua llty MU agementD trict2 BOERR-COMP OHP OR 100,000 BTU) 1.7
Y. No- ( FZ4 I # s�V
v
4haveread the haze a materials requirements under Chapter 6.950! BOILFR-COMP(OVER IW,OWBM
the Glifomia Health&Safety Code,Sections 25505,25533 and 25534.1
understand that lfthe building does not mrently have a tenant,that It is my NEW RESIDENTIAL MECA. SQ.Fr. ash /1 a�.asea
r ibilltytordl theoccupanto(the requlremenbwhichmusibemet Of ftm9}Bily
prior Issuance Of a C/�ry}Irate Of coq
ne cratthorsud agent Ded ISSUED BY; kIr
TOTAL:
OFFICE COPY
i