21335APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE B OINT PEN ONLY
Build],, Project identmcamnPERMIT
Building Address: „ p
N `
NO.
21335
wee s ane: ne:
so L� 97968
CITY OF CUPER11NO-BUILDINGDIVISION
APPLICATION / PERMIT
A
IV1'
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Contraao a anot: Lic, Na
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BUILDING-ELECTMCAI PLUMBING-MKL nil AL
CATEGORY
C I
Archit /Engbaer. Lk. No:
NC�
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
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Address:/9/ ��%��f7. �? ��C W
PERMTISSUANCE
LICENSEDCONTRACTOR'SDECLARATION
IN mbyaffum(hat l am Bcensed under provWonsofChapter9(mmmenc
Ingwlth SMfon70110)of Dlvitlon3ofthe Businessand Profeta onsCode,and my
license Is In full d effect.
Llmmai Lk.a
APPLIANCMIZESIDENTUL "—` .'IyrulJOB
DFSCR0710N
PANELS
a
Dat Cordracta
_ ; -- (
/
ARCHITBCPS DATIO
I understand my plans shall be used as public reavrda
OVER10sil
SQ. FF. FLOOR AREA
E/SQ.FT.
Licensed Professional
SIGNS EL
SPECIALCEiCNT%
OWNER -BUILDER DECLARATION
I hereby affirethat I am exempt from the Contractor's License Law for the
following redound. (Section 70315, Business and Professions Code: Any dty or
countywhlA requbua permit to commid, alter, Improve, demolish,compalr
'
TEMP. METER ORPOL$INSf.
any strocturctatemeits hathebalso pursuantt the[fmavions of to
!Ile a signed statement that M Is licensed punuanl to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) o, Divi-
slon3 of the Buslnemand Professions Code)orthat he Is exempt thercfromand
the basis for the alleged exemption. Any violation of Section 70315 by anyr
applicant lots permit subjects the applicant toa civil penalty elect more than
POWER DEVICES
gW5fMINC ELIEC W
OUTLETSSWITC `
VALUATION
a J✓V
NEIMRFSIDFNTC ELECTR FT.
five hundred dollars($5DO).
[-]Los owner o( the property, or my employees with wages as their sok
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure Is net Intended or offend for
`-
eale L5m, 70K Businessland Professions Code. TM Contractors License Law
does not apply mad owner khi.toth.property who bulldsoyim,pvidhdtor and
whadoem (hat such
khimuendedorwferedghhiowns. pl.If,
0.L. OI1P
F,CJ)/
RFS. UNITS
nts am a er, the
however,
improvements Intended oro0ercmplstomthe nerebugdorwdlhgve
Improvement Isaold wl(hlnorayeam(completlogtheowner-bu0d<rwlll M1ave
0B,Lwrden of proving that he did not build or Improve for purpose of sale.).
LJ 1 as owner of the m
p perry, am exclusively contracting and Pro with Ilansed
on to Code:
Business and IoM
construct the project (Sec. 70Kapply
QTY, BIN PER FEE
HADD ZONE
APN
PERMIT ISSUANC
The Co t
71a Contrcor's License law does no apply to an owner d property who
property
Wilds or Improves thereon, and who conlntle for such ptojeds with a
Yorfs) Bcensed punuanttolhe Contractor's License Law.
I_f I am exempt under Sec. 0 k P C for this reason
AL71A-D �-JAM
FEE SUMMARY
BACK FLO PRT T. *
DRAINS ,A
ANITARY Y_ N_
RECFTI'T a
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby aHl m that I M1rve a certl0ate of consent m ml( -Insure, ora
certifkdeof Wmlumn ComperuaBon Insurance ora certl(kd ropy there of fgec.
3800, Lab C.)
Po11ryM
FIXTl7RES PER �.
SCHOOL TAX Y N-
RECEIPT M
GAS�EA. SYSTEM -1 INC40 5
PARK FEE Y N
RECQPT P
- xf.V ,`j/F
Cam any
GAS EA. SYSTEM-OVER4(EA)
BUILDING DIVISION FEES
MCcifiied copy Is hercbytumIs city
MCertNed ropy Is (lied with the tlty Inspection division.
CERTIFICATE OF EXEMPFION FROM WORKERS'
GREASE/INDUSCAL WASTE MNTFRCIBaIDR
PLANCHECK FEE
PAID lb -d $��51
1L3,��
CRE SE7RAP
COMPENSATION INSURANCE
(Thlesectlon need net be completed If the permlt Is forme hundred dollen
SEWER-R-SAMTARY-STORM EA.7110F1'.
D2[C RCCCI fA
WATER HEATER W/VEN7/Q.ECTR
ENERGY FEE Y N
e
($100)orless.)
1 ani(ythat In the performance of thework forwhich this permit Is Issued,
WATER SYSTEM/TREATING
1 shall not employ any person In any mann r n to become wbject to the
a
Worken'CampFysaUom Lawn IIIDTI.. D
PAID
AppIIc.LM/
NOTICETOMf.—
Date Rtt i tlf
NEW RESIDENTIAL PIMB. SQFf.
after' dog this Certificate of Exemption, you
should beco lett to the Worker'Compensation provisions of the Labor
TOTAL:
Code, you =at fort hwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
BUILDING
SEISMIC FEE
I hereby affirmthat there Is actnstruelon lendingagency forthe perform
ance of the work for whlchthbgr Is issued (Sec. 3097, Civ. C.)
Lender's Name at/�
Lenders Address
1 cenifythat I have readthkappBationand patethatthe above information
Iscomed. I agree to complywith all cltyand county ordinances and elate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby author eir representatives of this
city to enter upon the abovamentloraed property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu pert less
against Ilabintles, jodgmnt
es, cokand expenses which may In any way accrue
ALMORADDTOMECH. -
Date Recei t>f
AIR HANDLING UNIT (TO
SUBTOTAL:
gelost said City In consequence oW granting of this permit.
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Slgrai—urj��rpdidicttMtrarmr Data
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAL3RDOUS MATERIALS DISCLOSURE
Will the appBant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Health andSafetyCodeSection 25532(a)2
Yee - o
s
Will the applla or nrebullding occupant use equipment or devices
HEATING UNIT CFO 100,000 BTU)
-
Date ReCeI tk
HEATING UNIT (OVER 100,000 BTU),
- TOTAL:
PAN RESID)
ISSUANCE DATE
which emit hazardous air contamiranb as defined by the Bay Area Air
Quality Management Di trict7
Cr A 1f�
t�ff771RYY
BOILER -COMP QHPOR 100,000 BTU)
,?Yrs o
have mad tM1 azo ous materlak requirements under Chaplet 6.95 of
the California health A Safety Code, Sections 25505,25533 and 25534. i
understand that If the building does not currently have a tenant, that It Is my
A/sr x 6 1990
WMM ,
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
responslbllitytu notify the occopant ofthe mqui mentawhichrrmstbemet
priortoesuanceofa Certl taeof Occupan
Owner
upon
ISSUEDBY:
Owner tori Date
TOTAL:
OFFICE COPY