21068 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.-
Building Add ress: 210681 LINDA /ST ®
rwonsm ;
one; A -
- a CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: 2�—rf.8
AAMSTILL No: APPLICATION / PERMIT
. BIDINGMECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL#
L o:
(�! C QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
All— G/JJ #' PERMATISSUANCE 'If lesal
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under prevWs onof Chapter 9(oummene APPLIANCESRIESIDENf1AA ]08 DESCRIPTION
Section 7000)of Division 3 ofthe Business and Pro(essionsCnde,and m
D-te is In fulLfpra agdsemlk
trs PANELS'
Llcenx Chn C/LLIr.M Td� /6O
Date Contndor
ARCHITECTS DECLARATION 701-1000 (' // - /
Ore Zp (understand my plamsshall be usedupublicremNs. OVER 1lD0 � �' SQ.FT.FLOOR AREA s/ .FT.
�C . I -
(u Licenx!Professional SIGNS PeLECTRICA /
jn 6 LL`7� mISP
OWNER-BUILDER DECLARATION T
p, Iherebyaffl nthatlameaemptfmmthe Contmdor'e Licenx Law(m a SPECGLC]RCUfT/
ZoEE..a followingreason.(Section 70315,Business and Pro(esslons Code:An d r I- wL ,}, Ii
rm�, county wich requirma pemdttocorutmcl,alter,improve,dennlbh,orrepa TFMI' ��ORPOLE!NST. 1-
'� ya fink
priortoiIs Issuance,also requlresthe applicamforsuch permitto. .r ) - r
W U file a signed statement that he is licensed pursuant to the provisions of the IA9WFR DEV]CE
O0� C.rimvdor's LicmaoLaw(Chapter9(mmmeocingwlth SedEm70(0)ot Divi- a 1.,
3 skon3.fthe Businesaend Prolemlmm Code)orthathebemmptthemfmmand SWIMMING FOOL C VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any 0
< EA
five hundredapermit subjectstheappllcanttoa dull penalty ofnd morethan E ms}
five L as o ner of the OOLpro NEW ENTIALELFGTR_SQ.Fr.
❑I,as owner of the property,or my employees with wages r their dole STORIES TYPE CONSTRUCTION
a oum(Sec.7on,Rogers.and kandion,Cdurehe �tendedContactors icensed
C D sale(Bee. pply to an owner
property Code:TheCimprovrs es hemeMaw
c.�$ docs nonsuch roan owner ofprough hisobuilds nemoyees,povidedthatand
who doeseurh work hlmx8orthraugh hleownemployees,provided that such t3CC.GROl1P RES UNITS
Improvements ere not intended orofaird formle.If,however,lhebuildlegor TOTAL:
Improvement back!withinoneyearo(completbn,the owner-builderwlllhave
t rden of proving that he did not build or improve for purpose ofmle.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to commuct the project(See 7096,Business and Prufesslota Code: '
The Contractors License law does not apply to an owner of property who ALTER-DRAIN A VEM-WATER(EA)W Ilds or Improves thereon,and who mnlnds for such inwineir with a
cepp.duds)Bernard License to the Contractors LicenLaw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec B 4 P C for this reason
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
One R_ Y
WORK MAN COMPENSATION DECLARATION ETXiVRES PER TRAP SCHOOLT" Y_ N_
❑1 hereby affirm that 1 have• Insurance
a c o consent d pythence oracertifiRECEPr Y
3800,abte ofWorkers'CompematlonlrmuranceoracertBled oupytherro((Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,leis C.)
Poll Y RECGAS FA.SYSTEM-OVER4(PA) BUILDING DIVISION
Com any BUILDING DI VISION FEES
�Certlied copy Is hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection divlelon. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SRWER-SANITARY-STORM EA XpFI. Date Recei t#
(ibisess.) need cad be completed!(the permit is(Drone hundred dollar
(811 cedifess.) WATER HEATER W/VENT•/ELECTR ENERGY FEE Y N
Icertifythat In the perfommnce of lhewmk(or which this permit lelssued,
I shall not employ any person In any manner xu subj the WATER SYSTEM/TREATING
Workeri Co rasa mf 1 tocols. D te � PAID
0 Applicant f)/VV ✓11 nri� NEW RESIDENTIAL PLMB.
Z Z Date Revel t#
NOTTCETOAPPLICA :IL�ef ins n his Certificate of Exemption,you SQ•FT•
0 should become subject to the WorYm'Compermatlon provisions of the Labor - TOTAL:
it N Code,you most forthwith comply with such providers or this permit shall be BUILDING FE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iberebyaftlrm thatthereba oum/mction lending agency forthe perform, ELECTRIC FEE
M Z anceofthe workfor which this=dt is heated(Sec.3097,CN.C.) TOTAL:
02 Lender's Name PLUMBING FEE
LLI— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtlfythatlhavereadthbappliatlonandnatethattheabovein(ormnion
isouriect.lagreelocomplywlthaR cityand oauntyordlnancesand state laws PERMIT ISSUANCE FEES PAID:
T N relatingto Wlldingmmtndlon,and hereby authorize representativesofthe, -
F Z dtytoenteruponth.above-mentbnedpmpertyfm Wpedlon purpoxe, ALTMORADDTOMECH. Date Rl t#
V —
IN-)agree eCeP
to save,Indemnify an d keep harmless the City of Cupertino
agalnallabllltfinijudgencon,mneand miemeewhichmaylnanywayaccue AIRHANDONG UNI'T(ED 10,000CFM) SUBTOTAL:
ago WiCB
t yI mnce
nsequeor this pgrmlt.
_ AIR HANDLING!INR COVER 10,000CFM) CONSTRUCTION TAX
10"g"Wre of Appe ontrador Die` EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous BEATING UMT(TO 100,000 BTU) Date Recei f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCrDl1u
n25532(a)7 HEATING UNIT(OVER 1W,OW BTU) TOTAL: l
Yea
Ili the 111c it ulldingo mpantuxequipmentwdeviccs . VENTILA770N FAN(SINGLE RESIDE ISSUANCE DATE
whlcl hanrdorelwntam defied bythe Bay Area Air
. Quality Marmgemen BOILER-COMP OHP OR 100,DM BTU)
4Yce
have real theThatertais rcqulremcnH undor Chapter G95 of BOILER-COMP(OVER SEP e3,�,
the Calllomla Heaode,Sections 7.5505,75533 end 75536.! 4 9(]f]
understand that lfcee not arrcntly M1avcatenanL that It is my NEW RESIDENTIAL MECH. SQ.W. Jl/reaponslbllity tonpant of the requirements which=at be met
prior to Issuance of CWfik.tc ofOm
mer or cul Dried age Date ISSUED BY:
TOTAL:
OFFICE COPY