21710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'et Wentlfcatlon 1 PKRhfITNO.
Building Address: `Or plan
21710
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A A
e , CITY OF CUPE'RTINO-BUILDING DIVISION
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ctor, ame: Lt Nmq APPLICATION /PERMITZr -Y (1/ BUILDING-ELECIRICALPLUMBING-MDCHAMCAL CATEGORY CONTROL N
ect/ gfneer. //; LI No:
r7 ACWS_'� BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Add...
PERMRISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat O)ofD( siolicen3aftheerprovisions and PrfChapter ssions9(mmmenc- APPLIANCESAES[DEMTAL JOB DFSRB710N
Ingwlth5ectio 17000)ofd die n3./the Buslnevand ProfemlansC.de,and my
Ilrenra is in full f and Afect [ �7 /� /y PANELS
License in Lie.N 7 -�dl/91a�
Date Contrator — UP TO 200ANIPS
ARCHITECTS DECLARATION W14000AMPS
SQ.FT.FLOOR AREA f/SQ.Fr.
Op: [understand my plans.haBbe usedapubllc rtosd.. 1 �.
NG i4s a
O Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SI'GCIALCIRCUIT/MISC /
Iherebyafflrmthat Is.exempt from the Contractors License Law for the
d9 'n folloavNg rtawn.(Section]m15,Bmines and Professions Code:Any tty or
;"'� coil.tywhichrequlresapermittocomtmMalter,lmpmve,demolbh,orrepalr TFl"P.MLT[R OR POLE INST. �•
anystructure prtarto ltatwarcgalso requlrestheappUmnt for such permit to POWER DEVICES
K 0 Ole a signed statement that he Is licensed pursuant to the provisions of the
3LLGContractor's License Law(Chapter9(oumtb
mencing with Sen 7000)of Div]-
05 yon Sof the Business and ProfesionsCode)orthat he b eaempt themfmmand SWIMMING IDOL ELECTRIC VALUATION
p5 SSI the basis for the alleged exemption. Any violation of Sohn 7m L5 by any OUTLETSSWITC"HR-Fapphcntforapemdtsubjed.theapplicantt.advllpenaltyd.a.rctlun Y five 1,as o nerdolof ( ,M. N 1STORI �TYPs ECONMUCTION
❑I,as owner of the property,or my euctum In with wage as there role< compensation,wllldothe woI'miestheaute:TheCnt seieorofferedfor Uk
O salenec. pply to an ossandfpsopety Coderhe ContractorsUm.ns themar Law
whorl applytoanownerdthroug ywhonempor imprwvided tohandOCC.GROUP RES.UNITS
whadvc.-t..M.k mselforthrough hlsow ie.IL oweprovidedthatsuchimprov.menbareno[(mendedoro(fertd(orale.If,however,thebuiWingor
t Nenofpmving that he did net build or Improve for purpose of.ale.). Qry, LUMFLOOD TONE APN
"1,as owner of the property,am exclusively contracting with licensed PERMIT NUANcontracton to construct the project(Sec.7W4,Business and Professions Code:
The Contrstors License Law don no apply to an owner of property who AL'hR-DRAIN&VIM-WATER(FA)
Wilds or Improves themon,and who contracts for such plojncs with a FEE SUMMARY
c,,33LLtr,anor(s)llcenxd pursuant to the Contractor's License Law. BAIX ELOWI'ROTILT.DEVICE
IJ I am exempt under Sec B &P C for this re
awn DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner ECLDatRFLF]I'I'N
WORKMAN COMPENSATION DECLARATION FIX.NRESPERTRAP SCIBOOLTAX Y N_
❑I teof or icon that I have•certificate of consent to opy tnvm,ora RECEIPT N
m00,Lab ofWorken CompewHonlnsurance ora cetifled copy thert.f(Soo. GAS EA.SYSTEM-1 INCA OUTLETS - PARR FEE Y N
380(1,Lab CJ —
I'ticy N DING DI N
Com env ✓a<ip P�-a -•l.. GAS EA.SYSILM-0VERN(EA)
BUILDING DIVISION ISION FEES
�CeYOMIcopyb herebyfurnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
[ Certtfied copy is filed with the city impectlon division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID �Jt
INSURANCE
BURANCE SEWERSANTTARY-STORM EA.b10F7. DateReLLL'1 (N �7V
(!'hie xtbn need nest be comp)TI tINSURRbforonc hundred dollen
(51Be)orlm
Icer0
I that in the performance.(the work forwMch this permit is issued, WATER}IFATE2 W/VENT/ELECTR ENERGYFEE Y N
1 shall not employ any person In any manner so as to become subject to the WATCR SYSDM/TREATING .
Worker!Compenatlon Laws.l Callfomla.Date PAID
Z = Applicant NEW RESIDENTIAL PLMB. SQ.FT. Dale Recel 1p
NOTICE TO MPLICANT:1(after making this Certificate of Eaemptlon,you
Fshould bewm.subjet to the W.rkeri Compensatl.n provisions fthe Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall be
LU W j doomed revoked. - K151Q.cell
W BUILDING •'E— CONSTRUCTION LENDING AGEncY SEISMIC FEE
CL IhembyafOm that then b awnstrution lending agency for the perform ELECTRIC IEE
Z ane,of the workfor which this permit is blued c.3097,Civ.C.) TOTAL: x
- U O Lader,NamePLUMBING FEE q
Lt. l- Le.aer.Aaares. / QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Indllythmlhave mdthbappllcatlonaM state thatthe above Into ion /�
bctingt 1.grsemc.mplywRh and hereby
muntyoa,reprmand ststelaws PERMIT LSSUANCE FEES —��
} N rclatoenterui upon
constrotlon,and hereby property
ori nrtprexntativn.(this �� 9l��
Z
cityCWe)aeree to the above-mentioned propertyfor inspection of Cape. ALTER OR ADD TOMECH.
_ (Wc)agree t.ave,indemnify and keep es which
the City o(Cupo crue D e RCCCiPIN
ag.lmtli.idCim,pdgmequence costs of expenses which mayln anywayamue AER HANDLING UNIT 8010,000 CFM) SUBTOTAL:
against Bald City In con.equenQ of the ming.(this permit.
AIRHANDUNGUNTT(OVER lQ=CFM) CONSTRUCTION TAX S•
C. 0 J. / �� CON R CTION T?XIS
SignaNrc of Appli /Conte Date IXHAWT}IOOD(W/DIJC77 Y (�
lARDOUS MATERIALS Of LOSURE q
Willtheappliunt orfutum building occupant store or handle her relous 1TEATING UNIT(TO 100,000 BTU) Date RCcel fk
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
1 health and Safety Code Section 75532b)r FIFATINC UNIT(OVER 100,000 BTU) TOTAL•
Yes �]No
Will the applicant or future building otupant uxequlpmantordevim VENIILAITON FAN(SINGLE RFSID) ISSUANCE DATE
which emit haardous air meta Mrants as dented by the Bay Area Air
. QualitY o
Management Di❑I�IrIN7 BOILER-COMP OFm 100,0100,0110OR 1 , BTU)
?have ad the fiazardo IL
materials requirements under Chapter 6.95 of BOER-COMP(OVE21w,"BTU)
the California Health&Safety Code,SeCbm 25505,25533 and LSSM. I SEB 1 1991
undemisnd EM
that if the building does not currently have a tenant that it N my NEW RESIDIAL MECH. SQ.FT.
rospomibllity to notify the occupant of the mguiremente which must be met
priceto Lsauance d aCetiOcateo! c panty.
G Tl ! —Z-- d e f
Owner.rauth xdagent Date ISSUED OY\\
TOTAL: VVV
OFFICE COPY