21079 - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PLESMUTNO.
B.Bdipg Addre.s: 210'7 9
�' f � S/ .lt n9t6v P1.
Owner'sName:
IJaV( bl Lai + clI q96 74' CITY OF CUPERTINO-BUILDING DIVISION / C
Contractors Name: Lie.No: APPLICATION / PERMIT ( '6 "—
o: BIJILDINGELECITUCA]PLUMBING-MECHAtx7CAL CATEGORY CONTROL X Arehbect/Engineer. Llc.N
QIY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcas: PERMITISSUANCE - eDy El
Lmi that EOCONTRACTOR'S DECLARATION
Ihereby
ectionsm(ftoiHmlicensed cHug essannsof C..l.a.9(comrnmc APPLIANCES-RESIDENTIAL •JOB DFSCRNHON
2ranh Section 7000)of Division 3ofthe Busine,sand Proleaelan.C-ode,and my' - ''
licence is in full force and effect: PANES
Chss LIC X
Date ract (T
Date Contor Il
ARCHITECTS DECLARATION 201-I0 OAMPS
P❑❑±±roO ZpC I understand my plans shall be used an public records, - OVER 10DO AMPS; SQ.FT,FLOOR AREA
E uT Licensed Professional SIGNS ELECTRICAL
<6 OWNER•BUILD£R DECLARATION ev'.f
in E7 BPECIAL CBtCIIIT/MLSC V
owinghereby af@mlbatlam31.5,B from the d Praictor'.Licence Law fort he
7 following mason.(Section 7R'i1.5,Business and Professions Code:Any city or '
Z F+� TEMP.ME[TR ORPOLE INSC.
countywhlch riartoes permittbcowtrvuirestheaprovgdemoWh,armit tr
anyetrvdure prbrta Its issuance,also requlmlheapplant(orauch permit to POWER DEVICES
IPI Q file s dgned statement that he In licensed pursuant to the provisions of the
Contractor.License Law(Chapter9(comrreneingwith Section 7000)of Dtvl- SWIMMI NG POOL ELECTRIC VALUATION
the
FSO eloolofthe Bualnessand Pmfessbns Ccde)orthat hebexempttherefmenael
the basis for the alleged exemption. Any violation of Stolon MISS by any 9 � � O
appBcant fora permit subjects the applicant ton civil penalty et not morethan / OUTLETSSWITCHESHXTURES / U
five uadred dollen($500). NEW READ ECTR SQ.FT. SIOWE TYPE CONSTRUCTION
�n I s owner of the property,or my employees with wages as their sole
co n�) ••nsation,will clothe work,andthestructure R not Intended or offered for
O sale(Sec.7044,Business and Pndegums Code:The Contractors License law
�$ does notapply to an owner of property who builds or improves thereon,and OCC.GROUP RES UMTS
F who duassuchwork hlmselforthrough Nsownemployees,provided that.eh
improvements an not Intended oroflered Eurasia.If,howevep thebullding or TOTAL:
improvement iasold withlnoneyearofcomplmiogtheowner-builderwlll have
tgg*rden of proving that he did not build or Improve for purpose ofsale.). QTY. . PLUMBING PERNIrr FEE FLOOD"/DNE APN
Lj L as owner of the property,am exclusively Motwung-h limned pgRMfp ISSU
ANIE
contractors to corutrect the projed(Sec.7074,Business and Profession,Code:
The Contndurs License Law does not apply to an owner of property who ALTER-DRAIN k A
builds or improves thereon,and who contracts for such pip"with a -
cgD7(actor(.)licensed pursuant to the Contractor's License Law. - FEE SUMMARY
[_J I ice excel under Sec B 4 P C for this ma cn BACKFLOW PROTECT.
DRAINS FLOOR ROO , ND. SANITARY Y N
• Owner Z.
Date IBB_ RECFJIPIX—
WORKMANC 1P AT ION DECLARATION SCJ 700E TAX Y N
1 hereby alarm that I have a certlflate of consent to sel-Insure,ora FLXTURES PER TRA REC®PI'X
3800,Lab e
certificate ofWorkeri Compnuation Insurance ora omitted copy thereof(Sac. CAS EA.SYSfF3.f-FIN PARKFEE Y N
Policy X GAS G.SYSTEM- (EA RECEIPT X
Cram any BUILDING DIVISION FEES
CertNed copy Is hereby filed
the cid. GREASEANDUSTRL W TOR PLANCHECK FEE
�Ccrtified copy V toed with the Aly impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
INSURANCE
NSURANCE 2
(TElacenion need not be camel TI Npermit bforonehundred dollars SEWER-SANITARY-STORM EA. Date Recei t#
(SIM)or leas.) WAER HEATER W/VENT/ELECTR ENERGY FEE Y N
m
I artily that In the perfonnceuf the work forwhlch this permit is Issued, —
I shall not employ any person In any manner soas to become subject to the WATER SYSTEM/7RGTTNG '
WDrkers'Compensation Lawsof California. Data PAID '
Z Applicant Date. Recei t#
Z O NOTICE TO APPLICANT:B,after making this Certificate of Exemption,you NEW RESIDENTIAL ELMS. SQkT.
Fshould becomesubject to the Workers'Compenation proWions of the labor TOTAL:
N Code,you must forthwith comply with such provision or this permit shall be B E U
deemed revoked.,
aCONSTRUCTION LENDING AGENCY - SEISMIC FEE �• G
l hereby affirm that there b a cdastrvAlon lending agency for the perforrry ELECTRIC FEE .
7 Z ance of the work for which thin permit b Issued(See 3097,Civ.C.) TOTAL
O O Iendae.Name - PLUMBING FEE
LL M- Iandce.Addmss Q'IY. MECHANICAL PERMIT FEE, MECHANICALFEE
.O W IarUfythatlhavereadthsappliatlonandrtatethattheabovelnformmion
is correct.I agmelocomplywith al cityand countyordleancesand nate law. PERMTTISSUANCE a UD FEES PAID:
} 9L retati ng to building construction,and hereby authorize representatives of this
F Z ' city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date ROCej [#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino p
age rat llabi ties,la dgment., amend expenses which may In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOT
AL•
TM44 ityI sequeneoft janIng of this permit.
(V"L-10 AIR HANDLING EMT(OVER IO,OWCFM) CONSTRUCFIONTAX
SI 'nature of Applicant/ mractor ,Date ' EXHAUST I IOOD(W/DUCT) �. CONSTRUCTION TAX PAID:'
HAZARDOUS MATERIALS DISCLOSURE Fill the appllcant or future building occupant store or handle haurdous HEATING UNIT CM 100,ODO BTU) Date ReCel t#
material as defined by the Cupertino Munldpal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ye. - No
Will the applicant or(u ie building occupant use equipment or devicesVENTILATION PAN(SINGLE RESID) ISSUANCE DATE "
which emit hazardous air contaminants as ele0oed by the flay Area Air PAMQuality Management District? BOILER-COMP OHPOR 100,0(0 BTU)
Ye, ❑No
havereadthebazardous rrualerialsrequimmen underChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health A,Safety Code,Sections 25505,25573 and 25534. I OPT.
understand that if the building does net currently have.tenant,that it is my NEW RESIDENTIAL MIECIT. SQ.ITT, q�4•Q'
resporuibi try to notify thart ofile en lulmrrenb which must be met
brio ante aCertlRo(e oEOccuppnry. of CU
l'r /V••Z`"�A b U7.W
Owner or authorized agent Date
TOTAL: ISSUED BY:A_ C
.
OFFICE COPY