21905/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Build -Ing Prom Identification I
Building Address:
,i efiAc�27i�w c� 9soif
PERMITNO.
21905
ante:j' one:
W�/ ,t%4, 17/C6M/j3
CITY OF CUPERTIN0.6UILDING DIVISION
APPLICATION / PERMIT
AA
Contnnm
or'.Nae: Lie. n:
BUILDING EMECTRICALPLUMBING-MSCI IAMCAL
CATEGORY
CONTROL N� L '[l a
srchlten/Engineer. Lie. Nm
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Addre.
POtMITISSUANCE
bl El ❑ ❑
I/�
LICENSED CONTRACTOR'S DECLARATION
Ihereby.ffiren that cct1on7000)olam licensedunderBusiexuaioneof Cssions9(mmmm
inenseESection force effeon3oftheBuslnesand ProfcasionaCode, and my
license la In WB fora and
API'LIANCFSRENDENTAL
]OB DESCRIPTION
t. l 1 / r�Q
O r`l `N4 U
PANELS
LicenseClas LICK
c. #
'�fil—tJ
Date Contractor
301-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OVERIODOAMPS
SQ. FT. FLOOR AREA
r�YD
$/SQ. Fr. p
7G{l C 2--
SIGNSELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
/ J ��� 6 V
TQ{p METER OR POLE INST.
following Mason. Cecil.7031.5, Business and Professions Code: Any city or
.o tywhichrequlresapemdttowmtrun,altegimpmve,demoltsh,orrepalr
I �2 0
anystmdumprmtoibbsuance,aMrequlmatheapplicantfwauaperMtto
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
1 {1
Y q 6 0
SWU{MNG TOOL ELECTRIC
OUTLETSSWITCFIESFI%TURES
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3 of the Business and ProfessionsCode) orthat he la exempttherefromand
the basis for the alleged exemption. Any violation of Section 70115 by any
appH tforapermitsubjenstheappRanttoadvilpemltyofnm=mthan
fi, dred dollars(4500).
I, a. owner of the property, or my employ. with wages m he wle
VALUATION O D
' 3 O Q V
NE=ISSUANCE
STORIES
TYPE CONSfRUCT10N
ompensation,wBldothe work. and the structure brwl Wtendcd or oBc=or vieOk:c.7054,BusinessandPro WmCade:TMContranoes Licerue Lawdonnaapplytoanowomofpropertywhobuild.orimprwnthereon,a..d
whodeesauchworkhimxlforthrough hisownemployes, provided that suchimprovements are not Intended oroffered for sale. ILhowweqthebuildingorimprovement
OCC.GROUP
RES. UNIT
Issold within oneyearofcompletlon, theowner-builderwlll have
tl)L, urden of proving that W did not build or Improve for purpose of sale.).
Lj L as owner of the property, am exclusively centra...... with licensed
contractors to construct the project (Sec. 7064, Business and Professors Code:
QTY,
FLOOD ZONE
APN
PERMIT
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such pyojects with a
chow licensed am exam pursuant to the Convanor. Line.. Law. 14, n
j$/�B&
ALTER -DRAW & VENT- WATER (EM
FEE SUMMARY
.AFLOW PROTECT. DEVICE
IX
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_N_
RECE;rT R
/Cffn
/4146aa
Owner o Date /rT/�%—
J./WORKMAN COMPENSATION DECLARATION
❑1 h by affirm that I have a certmcate of consent to sell-Wwm, o a
cert.flmteofWorken'Compensatlonlns mnceeaamn.fkdmpythereof(Sec.
lab CJ
Policy
Polity q
FIXIVRF_S PER TRAP
SCHOOLTAX Y_ N_
RECEIPT N
GAS EA. SYSTEMINC.60UTLETS
PARK FEE Y N
RECEIPT N
GAS EA. SYSTEM -OVER 4 (FA)
C
Go any
BUILDING DI VISION FEES
Ectridied copy ts hereby furnished.
Certified copy b filed with the my, inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
MEA. 20OFT.
COMPENSATION INSURANCESEWER-$ATARY-STORM
(ThleaecUan nen, na be completed If the perMt la forom hundred dollars
Date Remi I#
WATER HEATER IN/vFbPF/ELECTR
ENERGYFEE Y_ N_
['
(SIM)orles.)
1 cortifythat in the performance of the weak forwhich this permit is Weed,
WATER SYSTEM/TREATING
I shall not employ an/ person In any Ranner so as to become subject to the
Worken'Compensatian Laws of Gll(ornla. Date
PAID _
NEWRESIDENTIALPLMIL SQ.FT.
Applicant
DatC Recti t#
NOTICE TO APPLICANT: IL.her maklog this Certlflote of Exemption, you
should become subject to the Workers''Compensation provisions ofthe Labor
TOTAL:
�i
�V'
-
BUILDING E
7 6—•a#s9
Code, you mu at forthwith comply with such provisions mthh, permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I SEISMIC FEE
c_v_
I hereby afflrenthat there Is a construction lending agency for the perform-
once of the work for which this permit N Wood (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I cedlfy !hail have readthisapphatlonand statethat lheaWve information
broingtobagree to comply with all city and ceuntyordinaregmatigate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEE
relat.ngtM,.poingv.Wr ion,an,herebyayfre inrepresnpurpos ofthio
propertyml Wpmlot p fCuperses.
nt(Wa)aeree to theabovemnify an
(We) agree to save, indemnify an d keep harmless the City ofCupertino
againstliabilities,n expenses which may In anywayatttue
cortof
ALTEROR ADD'IY)MECH.
ZAKA Z--
[e Receipt#
AIR HANDLING UNIT (TOI0,000CFM)
SUBTOTAL:
consents,
the
against.. Ity W roc a of the granting of this permit.
/
AIR HANDLING UNR (OVER 10,1%IOCFM)
CONSTRUCTION TAX
Sign u 0 Applicant/Contractor Date -
IXHAUS'T HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATERIAL ISCLOSURE
W.11theappliant or town, building occupant store or handle havardous
HEATING UNIT (TO I00,000 BTU)
Date Recei t#
material as defined by the Cupertino Municipal Calc, Chapter 9.11, and the
I{eallh and Safety Code Section 25532(a)2
t �] No
Will the applicant or future building occupant use equipment or devices
Will
which emit havrdous air contaminants as dented by the Bay Area At,
IRy Management DistrIct7
YY. F❑1 No
I love read the haaardous materials requlmmenn under Chapter 6.95 of
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VFNDLATION FAN (SINGLE RESID)
ISSUANCE DATE
y,
��/s/q� /.NIA �e'%�/✓
Kis? �^v�."r.I�T
BOILER -CAMP OHP DR l00,f100 BTU)
BOfLFR-CO.MP(OVER 100,000 BTU)
19
the CaWomla Health Code, Sections 25505,75533 and 75536. 1—T
understand that if the building does not m rrently have a tenant that it is my
up
-
NEW RESIDENTIAL MECH. FRET
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
�j�sa aassWh�
MY , VYQE?at'IIU
ISSUED B f
Owner or authorimd agent Date
TOTAL:
OFFICE COPY v