21821 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Potica Identification PEILUdT NO.
Building d 7 ;� 1 21821
e: A f A A
7125- CITY OFCUPERTTION i PERMIT
DIVISION _ G_ O/
eontraaor'sLha�me—:� Li<.No: APPLICATION / PERMIT Ofy
r 236 BLALDINGELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL N
6T4 ELECTRICPERMIT " " FEE `-BUILDING PERMIT INFO_ '
Add. LICENSED CONTRSEIpPFRV4TISSUANCE
Ihereby affirm'list) licensed
order
pmv19....
fCha .,9(comAPPLIANCESRESIDFNITAL
❑JOB D.ESCR❑IION
ingwlthSeMon700o)0(Dvi.i.n3.ftha B.sinesand PminsioaCcode, ndl my
❑
license is In hjfq def(en. " O.J PANELS
.•
coni CV Cme
Date CHITECr ARCHITECTS DECLARATION OVERwAMPS
0Z [understand my plain shag be used as public records. OVER 1000 AMP"' SQ.Ff.FLOOR AREA E/s().FT.
5 O
d oI Licensed Professional SIGNS ELECTRICAL
6 w OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Ihcreby.ffl.that l am exempt from the Contractors License Law for the
following reason.(Section 7mlS,Buslneaand Professions Code:Any city or TpAiP.METQt OR POLE[NSI'.
county which mituhn a permit toconstruct,alter,Impmve,demolish,orrepalr
m$$ anystm=mpnortoisl ams aborequmestheappkontfOsuchpermittm Il7W'ER DEVICES
2 O E. m
V file a signed statement that he is licensed pursuant to the pvbns loof the
`� Contractor's License Law(Chapter 9(comurencing with Section 7000)of Divi- SWIMMING POOL ELECT VALUA�l�J ON
sl
5%OS on3mf the Business and en
Pmflam Code)mthb at he exempt therefromand / OV
^yrs the basis for the alleged exemption. Any violation of Section 7e41S by any OUTLETSSWITCHESRX'NR6` f
at��-� appBant(ora permitsubjects th<applicant toa civil povlty of stmt mare than
five hundred dollars($M. NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
J .. F1 1,as owner of the property,or my employees with wages as their sole
Z� c.inpenstation,willciothe work.and thestruatum ts not intended or offeredlor
♦<F p sale(Sec.7644,Business and Profesdomu Cade:The Contractor's License Lw
does not apply to an owner of property who Wilds or improves thereon,and =.CROUP RES.UNT[S
.- whodm suchworkhimselforthroughhisownempinyeegprovidedthat such
improvements arc not Intended oroflered for sale.If,however,thebullding or AL: ,—
improvement u sold within one yearolcompletion,the ownenbuilder will have
the,*rden of proving that he did not Wild or improve for purpose of sale.). ('?TY: "' PLUMBING PER I ,( FEEETAOD'IANE APN
L-J L as Owner of the property,am exclusively contracting with licensed PQLNIT ISSUANCE
contractors tin construct the pmject(Sec 7064,Business and Professions Code:
The Contractors License Law does not apply to sn owner d property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or improves thereon,and who contracts for such pPlects with a FEE SUMMARY.',
ffy�Tirfor(s)licensed pursuant to the Contractors License Law. ggCC FLOW PROTECT.DEVICE
I am exempt ander Sec as
B &P C for this reon
DRAINS FLOOR ROOF,AREA GOND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FDTURFS PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a can{Rote of consent to self-Insure,ora RECEPT N
certificate of WorkOi Comperuatimnlnsurana oracertiflod copythereof(Sec. GAS EA SYSTEM-1 BVC4 OUTLETS PARK FEE Y N-
3800,Lab C.) RECEIPT N
Policy GAS EA SYSTEM-0VER4(EA) BUILDING DIVISIONFEES
Com a
mined copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
o Cenlfied copy is(Bed with the city impsction division.
CERTIFICATE OF LYETSPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.]00E-r. Date Recei t#
(Thlssley
not be completed if the permit b for one hundred dollars
(3100)wlWATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
Iecrifperfo ecoftheworkforwhlc this rmttlsf, ed,
I shall sorty o i any manner ro to the WATERSYSTLM/TREATINGPAID
Workena 1lfomla.Date
O Z Applicant NEWREMDLNTIALPLMB. SQ.FT. Dale Recei t#
ZONOTICE :I a rmaWng this Certifi to of emptloo,you
zhouldbeconesubjectto a orkers'Compensation provisions of the Labor TOTAL:
CCN Code,you most forthwith comply with such provtsbns or this permit shall be - BUILDING "E
deemed revoYad. SEISMIC FEE
W CONSTRUCTION LENDING AGENCY
LL Ihereby affmm�that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z ance of the work lorwbichthb permit Is lssued(se<.win.Cw.e)0 Lender's Naar PLUMBING FEE
LL I-
(� -Lndce.Addrcaa QTY. „`MECHANICAL PERMIT 'i FEE MECHANICAL FEE
O W I cortllythat l have readthbappliatmn and nate that the above information FEES PAID:
ucoct
rm .l agni comply withaBcityand couityonlinances and nate laws PERMIT ISSUANCE
1 rclatin skiing ronstructlan,and hereby authorize representatives o(thi+
Y y cit to teru n the abovc-mmentioned m f inspection u ses. AL TFRORADDTOMECH.
Z hereby
t ive Date Receipt#
~ ytwo agm to save,Indemnif an d keep harmless the City of Cupertino AIR HANDLING[IMT(TO l0,axi CEM)
V
against bit Ies,Pdc n ndeapenseswh",hmayinan yacrnae SUBTOTAL:
a aunt sty In roe encs mf graining o(thls le ,a CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,6w Clyd)
Si a real [leant "a or to D(HAUSTHOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZAR O AT occupy DISCLOS RE HEATING UNIT(TO IMM BTM
Will the efindbythutuprtiidingoicipan store or Code,
lchazardous _ Date Recei t#
rmterjal as defied by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTI)) TOTAL:
�]No VFNDL\TION FAN(SINGLE RESID) ISSUANCE DATE
Will lit the appllant or furore building occupant use equipment or devices
whkh emit hsvrdous air contaminants as defined by the Bay Area Air
.Quality Ma agement District? BOMFR-COMP 0HP OR 100,(1(0 BTM
tYv, No 000 BTU)
the hazaroasmatenals rcquimrnents underChapter6.95 of BOILER COMP(OVER 100, CC❑ (S991
lmlth&Ba/dy Code,Sectlore 25505,25533 and 2553.). 1 r1��.i t lfthebuildingdoes notcorrently have atewnr,that it unny NEW RESIDENTIAL MECHto std i —aOr of"arequirements which must be met ce ofa 10pastry.orirc agent �kEOTAL: L'EISSU
OFFICE COPY