21726 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PERMITNO.
BuBdui%,Vdmasr 21726
1 "aLAN 3{� �T - // 6 � P�WE &tZozK ei Ler-36
me. one. A A A IL
oR ' "e0 '/J CITY OF CUPERTINO-BUILDING DIVISION
• cnntrann aN. e: — ue.No: APPLICATION / PERMIT /� ��
3U� BUILDINGE.ECMCALPLUMBING-MEL MCAL CATEGORY CONTROLM
Arthltea/Engineer. •Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE 111 rkl� y�
LICIiNSGD CONTRACTOR'S DECLARATION
thereby afflrmthat l am licensed under provisions of Chapmr9(mmmemo APPLIANCESRESIDENTIAL JOB DESCRII'I'ION - -
ingwlthSectton7000)of DLviaon3 ofthseualnessand Profe..tomCo in,and my
license la In full fa anddfea. /�.3oO i''�f PANELS //�� ,,
DiaLiaCls: Cmar / S F W
Date I tc.# or
ARCHITECPS DECLARATION X)1-I0K)OAMPS
�Qt O/. I understand my plans shall be used as public records. OV SQ.FT.FLOOR AREA S/SQ.Fr.
m U Fj Licensed Professional SIGN
< OWNER-BUILDER DECLARATION mP
SPEC
Ihercbyafflrm that l am exempt from the Contractor's License Law for the LC j �-3
G O,'S following reason.(Section 7fB15,Bwlness and Prolsubna Code Any city or G
F7I-'� cvuntywhich requ(resapermit locmnstma,alter,impmve,demolkh,orrcpalr TEMP.ME77iIi INST.qq � 03
Y�Yg.a anystmdumpriertoltskmance,abomquirntheappli¢ntforsuchpermitto
C file a signed statement that he b licensee pursuant to the provisions of the BOWER I
�3u� ContudorsLicense Law(Chapter 9(mmmencingwith Seaton 7000)of�ivl- SWIMMING POOL ELECTRIC VALUATION
H�Og almn3oflhe Bualncasand ProfessWmCodc)arthat heke¢mptthertfromand -
yd the basis for the alleged exemption. Any violation of Seaton 7071.5 by any CC /
Di applicant lora permit subjectsthe applicant to a civil penalty of not mOUTLETS-SWITCHES-FIXTURES
than
five hundreddollarsof
P). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
�f?< M I,as owner l the property,or my employees with wage as their sok
compensation,willdotM1e work and thestroaum k not Intended or offered for
g O dile Sec.apply to ainow and f property
Cede:Ths Contractors LI¢nse Gw
�' >3 does not apply roan owner offprough who ncm orimp provid thereon,and
e-$^
who d¢ssuch swrk himself orthwgh Nsownemployma,provltlsd that such OCC.GROIIP RES,UNITS
Improvements am not Intended oroffered for sale.If,however,thebullding re TOTAL:
Improvement bsold withlnoneyearefcomplalomthcowner-budderw0l Tuve
trys�rdenof pmvingthat he didnet Wild or Improve forpurposeofsale.). QTY, PLUMBING PERMIT FEE
LJ L a.owner of the ro FLOOD aDMJE .APN
p rorty,am exclusively contracting with licensed PFRMITISSUANCE
ThecoriCo ors to ronstsun the w do (See.of apply
to nes and of property
Code:
MTs Contractor'.License Law does not apply ct an owner a(property who ALTER-DRAIN 4 VENT-WATER(EM _
Wild.t r Imprensa thereon, and who monad (¢such p ejects with a FEE SUMMARY
cgp(Iaam exempt
and rsuant to the Contractor'.License Gov. BAOC FLOW PROTECT.DEVICE
LII am exempt urWer Sec. B k P C for this mason
_ OUTSIDE TI ES
DRAINSFLOOR,ROOF,AREA,COND. SANITARY Y N_
Owner Dae RECE3I'1'X
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOL TAX Y_ N_
❑I hereby sfikrn that I have o Insurance
of consent m opyself-insure,hersof ora RECEIPT X
mrd/tarso/Worken'Compensatlon Wuran¢oraoenlfled mpythemof(Sec.
3800,Gb C) CAS FA.SYSTEMA INCA OUTLETS PARR FEE Y N
s
Ib11ryI - GAS EA.SYSTEM-0VER4(EA) ING DTX
Cm BUILDING DIVISION FF.IiS
oPCcrtlfied ropy b hereby filed
the city GREASEANDUSIRL WASTE INTERCEIrrOR PLANCHECK FEE
1�.Atertl(led copy b fled with the sty inspection division.�1 CERTIFLUTE OF EXM PFION FROM WOR K ERS' GRFASE7RAP PAID
COMPENSATION INSURANCESEWFRSANRARY-STORM EA.XI((IFT. Date Remi t sSES
(this section need not be completed if the permit Is forone hundred dollars _ P
' (f100)orlen0
1¢nify the in the performance o(the work for which thispermit is Issued, WATER HEATER W/VENT/ELDCTR ENERGYFEE Y N
I.hall not employ any person In any manner n u to berome subject to tM1e a
Workers'Compensation Law.of California. WA17R SYSTEM/TREATING Ill(ernla. Date AID
0 Z Applicant - NEW RESIDENTIAL"B. �.ET. Date Recel ti(
Z O NOTICETO APPLICANT:ILki
after mang thisCertBlcam.f Easmptioe,you
Hshould become subject to the Workers'Compensation provisions of the Labor IOTA ?
W Cade,you neat forthwith comply withsuch provisions or this permit shall be BUI TNG FEE d
deemed revoked.
(L — - CONSTRUCTION LeMING AGENCY SEISMIC FEE
O. Z Ihereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE r
ance of the work for which this permit k loved(Sec.309],Civ.C.) -
(,) O Lender's Name , I PLUMBING FEE
LL F Lenders Address f�_i� QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
ly
O W Imnifythal Mvsmadthuappli tlonandaatnthaitheabovelnformation
i+coaver. .gr¢tommply with all city and manly ordlnanaa and statelaws PIMPITE ISSUANCE FEE PA D. yry
} N rela0ngtobuildtngmnstrualegand Mrebyauthoromerpresentativesofthis �Y 9 1252
F Z sty to entarupon the above-mentbnN property for inspection purposes. ALTER OR ADD TO MECH. Date Reeel jell
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,judgments,costs and expenses which may to anyway same AIR HANDLING UNIT GO to,"CFM) SUBTOTAL:
againstsaid try In consequen¢of the granting of this pe It.
( ASR HANDLING UNIT(OVER 10,000C IMM, CONSTRUCTION TAX
Slgnaurso(Apli¢nt/Contractor , ` in EXHAUST HOOD(W/DUCT) CO TRSCCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS RE 6
Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO IW,000 BTU) ate Recei til
material as defined by the Cupertino Municipal Cade,Chapter 9.12 and the
ioa
tlthand Safely Cade Seaion75532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL:Ye MN.
Will theappllanterfutureWilding acovp.M.se squipr¢ntordevices VENHLATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdom air contaminantsas defined by the Bay Area Air
lily Management D'rstria7 BOILER-COMPOF4'OR 100,OUD BTU) bo—AM
❑F�No
i have read the haaa3o m
materials nequlrcents under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
the California dearth e.S.fety C.dc,Seainna25505,25533.na 235M.I FEB 141991
understand that if the building does not currently have a taunt, N that it my NEW RESIDENTIAL MECH. FT
SQ. .
responsibility to notify the occupant of the requirements which must be mot
prior to buancc ofd artllicate of Ocmpanq.
57.-A( c' l
,•elle Ind agent Dae ISSUED BY:�.a
TOTAL
OFFICE COPY