21915 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Prato Identification rf PERMITNO.
Building Address: Jr_ 21915
��s� Z9L .I v�
nere ams: one: p
Owners p, CITY OF CUPERTINO-BUILDING DIVISION _
contrxdors a k.No: APPLICATION I PERMIT 3 _
S BUILDING-ELMMCALMUMBING-MECHAMCAL CATEGORY CONTROL.M J�
J
Arc it /Engler".. I Lk.No: v
BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
AddreuseA� IPERMITISSUANCE �J ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflrmthat l am licensed under provisions of Chapur9(comment APPLIANCES-RESIDENTIAL JOB DL9C ON
Ingwith Seemr,701M)of Division 3ofthe Businessand ProfesslonsCode,and my
license is In full fi1q•and effect. PANELS V` �1
Limn U LIc.M 2'3 Q` _ e /
DateContmcter l..m /
ARCHITECTS DECLARATION 2II-1000 AMPS
W ZOC I understand my pbrashallbe used as public records. OVERIODOAMPS SQ.Ff.FLOOR AREA 5/:Q.Fr.
Fi o U Licensed Professional SIGNSELECTRICAL
<<�< OWNER-BUILDER DECLARATION SPECU LCIRCUIT/MLSC
l., Iherebyaf0rmthat l am exempt from the Commences License Law for the
_
Wfollowing reason.(Section 70115,Business and Professions Code:My city or
.8 TEMP.METER OR MILE INST.
PE cauntywhkh rcqulresa pemdlb alsore uirritheapnrve,demoLLeh,orrepalr
S any structurepaler telt that he nce,
also sed pursuant
t the provisions
to I'OWFR DEVICES
F�O the a signed statement that M b licensed pursuant to the provisloru of the
G61 Contractors License law(Chapter9(mmmeecingwlthSection7000)ofDivl-
rn SWBrthRNC POOL ELECTRIC
�}. sie basis he for the lle and Pemption. Any viothat lation f exempt therefrom and AIIONO�
(be baanforthealleged exemption. Anyviolationtolacan of Section 70315re any /G OUTLETSSWITCHESHXT[IRFS VLJ /r D
app0candred dollars
the applicant tea civil penalty of net more Qun
five hundred dollen he pr.
L as owner of the property, NEW RESIDENTIAL ELECTRSQ.FC. STORIESTYPE CONSIRIICHON
❑ p perty,orhe employers with r their
compensation,will do the Business and
andthestructure knot Intended or offered for
qsale(Sec.apply
to a now and f property Cody.The Contractors License law
Q{ don not apply to an owner of pror operty who builds or Improver lhereoR and OCC.GROUP RES.UNITS
E whodoessuchments am not even edoro Brod own".If,ho erverthe d that building
r
Improvements lntendreyear fcornprsa n,the ow owner
-builderwdingor TOTAL: ` (�
Improvementissoldwithln oroyearofcompletion,throwner-bulWerwlllhive
ttlf,¢irdeo of proving that he did not bund or improve for purpose ofuk.). QTY, PLUMBING PERMIT FEE FLOOD7DNE APN
LJ L as owner of the property,am exclusively=trading with licensed PERMCf ISSUANCE
contractee to construct the project(See,7010,Bualeenand Professions Code:
The Contractors License law does not apply to an owner of property who 2 ALTER-DRAIN&VENT-WATER(EA) -
Wilds or Improves themon, and who contracts for such projects with a FEE SUMMARY
�g6<act rut licensed pursuant to the Contractors Llceme Law. BACK FLOW PROTECT DEVICE
LII am exempt under Sec. B&P C for this maven
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT
WOR KAN COMPENSATION DECLARATION
MFATURES PER TRAPSCItOOL TAX Y_ N
❑I hereby affirm that I have a certificate of consent to self-Nwre,or a •� RECEIPTS
certificate of Workers'Compenaation Insurance ora rertlfird copy thereof(Sec. GAS EA.SYSIFM-1 INCA OUTLETS PARK FEE Y N
3800, CJ RECEIPT N
Polity#Y GAS EA.SYSTEM-OVER 0(EA)
Co�mpa ray - BUILDING DIVISION FEES -
I I Crti
ertmed copy it hereby furnished. GREASE/INDusIRL WASTE
INTERCEPTOR PLANCHECKFEE
Cefied copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPIHON FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.XIOFf. Date Recei t#
(This sedion need not be completed If the pemut lsforere hundred dollars
($1 rfs.) pp ENERGY FEE Y_ N_
Ie
0)orrsthat In the prdmce o
oanf thework foywhich this permit la loved, WATER HEATER W/VENT/ELSCT.R
I shall not employ any person In any eanneu4as to be me rob d the WATERSYSTEM/TREATING
Warken'Compe Ion sof Cali( s /ate / PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Dale Recei t#
Z O NOTICE TO MIGNT, fter I.Certificate of Exemption,you
should berome subjM tot o •Compensation provisions of the Labor TOTAL: 0
IN Code,you moat forthwith com th such provisions or this permR shall be BUILDING • C
W `J deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE s Iry
CL IhembyafRrmthat there b aconstruction lending agency for the perform (y ELECTRIC FEE c—co
D Z arta of the workforwhich this permit is bound(See.3097,Civ.C.) TOTAL: �Lt
O Q ]enders Name PLUMBING FEE atm
LL F- Iceders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtlfythatl have read this application and state thattheabovelnformatlon
6 iscorred.l agreeto comply with all city and county ordinances and Mate laws PERMIT ISSUANCE FEES PAID:
>- N relating to building construction,and hereby authorize representatives ofthb
I— city to enter upon the above�mentioned property for inspection purposes. ALTERORADDTOMECH.
Z Me)ag.to save,IndemNfy an d keep harmless the City of Cupertino Date R0Ce1Pt#
V agaWlBabNUn,Wdgmente,mats expenses which may in anywayaceme AIR HANDLING UNIT CFO 10,0DO CFM) SUBTOTAL:
against said City Ines Ola nc t granting o(thls permit.
AIR HANDLING UNIT(OVER IO,ODOCfM) CONSTRUCTION TAX
-- gatureof secant o actor - D.V EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
NA USMATERIALSDISCLO URC
Wlllthe appBca or(umrebullding occupant store or hand lehazalloua liEATINC UNIT(TO 100,000BN) Date Recei t#
rmteriolasdefine ythe Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Sedlon 2S532(z)7 HEATING UNIT(OVER 100,000 BTU] TOTAL:
❑Yes No
Will theapplicaet or Nreb.IldlrS occupantuseequipmentmdevices VENHLATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HPOR 100,IX0 BTU)
4YeaNo
haver"adthehu.quseuteriabmquimmntsunderChapter6.95of BOE.PRCOMP(OVER 100,000BTU)
the California Health&SafetyCode,SectMA
ions 75505,75533 and 75534. I '"
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MEIN. SQ.Ff. a 4/
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy, ,ak
Owner or authorized agent DateISSUED BY:
TOTAL:
OFFICE COPY