21739 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldir Project Identification OT G Z PERMIT NO.
Building Address:
it --I 91,_-%_ 21739
rs a - one: A A A
(� CITY OF CUPERTIN6BUILDING DIVISION
® Ta.w, amp: No: APPLICATION / PERMIT — L —CA \
BUILDINGELECTRICALPLUMBINGMDEI MCAL CATEGORY CONTROL
itect gin,
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO .
Address
PFRIAiISHUANCE
• LICENSED CONTRACIOCi DECLARATION
I hereby affirm that lam licensed under provulons of Chapter 9(commmc APPLIANCESRESIDEN'ML JOB DESCRIPTION
ingwlth Section7000)of Division 3 offflu Businessand Pro/nsloraCode,and my
license
ca 9I'h.u fob L reef. /�� ?; PANELS •�
Date —`�—Contractor !
ARCHITECTS DECLARATION 101.1000 AMPS
K OVER 1000 AMPS Fr.FLOOR AREA
O 7. I understand my plans shag be used ss public rends. e�Q� 5/SQ.Fi.
O
Licensed Professional SIGNSE CAL `\�
�QF - OWNER-BUILDER DECLARATION SPECIAL C + / '/ �•`
H 7p_ Ihercby alRmn that am exempt from the Contractor's License law for the ^ /
7P W following reason.(Section 7m15,Business and Professions Code:Any city or 7777/_ Z S llV//ccc'-IIf
Fya,a muntywhlch requlresapermittocovtaKeller,improve,demollsb.ar.palr 1EMP'M V U
5 8. any structure pdorto its Issuance,alsorttuimthe applicant fersuch permit to ) ypR DEVICES I
E o Ica OP
V file s signed statement that he is licensed pursuant to the provisions of the
F�c, Contractors License law(Cha 9(commencin with Section 7000)of Divi- SWIMMING C /
OQ slon3ofthe Buslnnaand PrefembvCode)arthrt he is exemptthereVALUATION(romand
e •.t
the beau
for the alleged exemption. Any t tola ioncavi ofnaltScale.7031.5 by nor room
OU(LEISSWITCHESITXRJRES ell,
applicant dredd.tLultsubjectsthe appllcanttoa dull penalty dnot morcthan -
m live hundred dollarshe pct.
f,ssowarll dot roe NEW RESIDENTIAL ELFLTR SQ.FI'. STORIES IYPECONSDRUCTION
�'P S
F-1
nsatlan,wllldothe work nasi eatsuaurycbno[iIntendedor offered for
❑ sole(Sec.7004,Business and Pro(easlons Code:The Contracmle License law
don not a pply to an owner of property,who builds or improves thereon,and
n-$^ who does such work himself orthrough his own employees,provided that such CCC.GROUP RFS UNITS
Improvements arc rot , TOTAL:
Improvement listed wIthinoneyearofaompletion,
the owner-bullderwlll have
th,£.�urden of proving that M did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to mvlmct the project(Sm 7004,Business and Prdessiov Code: PERMIT NUANCE
The Contractors License law don net apply to an owner of property,who ALTER-DRAIN&VFM-WATER IPA)
bunds or Improves thereon,and who contracts for such p(ojects with a FEE SUMMARY
cof,cter(s)licensed pursuant to the Contractors License Law. BAIX F1pW PROTECT.DEVICE
L�I am exempt under Sec B A P C for this reason
DRAINS.FLOOR RODE,AREA,GOND. SANITARY Y ' N_ .
Owner Date RECEB'1'N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP
certificateSCI100L TAX Y_ N_
r-11 hereby-!Ilam that I have a ceuounmcee of consent to selfdnsure,ora RECEIPT N
o/Worken'Comv
pestlonlvuranora certl(led copy thereof(Sec. GAS EA.SYSITM-t INC OUTLETS PARK FEE Y N
PuB lab C.)
Ibllcy N
ComCV' "C' CAS A.SYSTEM-OVER4(EA) BUILDING
DIVISION FEES
c,rtifiod
copy It hereby tum
ffCernfled copy u filed with theecity
inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ly
CERTIFICATE.OF EXEM PTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCESLIVEIT
R-SANARY-STORM EA.IIXIFT. Date Recei t# SSS
(Ihlssection need not be completed lithe permit is,for one hundred della.
(f)0°ceor less)
ndythat at In the performance o(the wark for which this Permit la lssued, WATER HEATER W/VENT/ET„ECTR ENERGYFEE Y N
I shall not employ any person In any runner se as to become subject to the WATER SYSTEM/TREATING f
Worke.'CompensatlonUwso/California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFI'. Dale Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fshould became subject to the Workers'Compevatlon provlslovofthe Labor TOTAL:
LO Code,you must forthwith comply with such provisions orthu permit shall be B TIDING 'E I
2.601
> deemed revoked.
W a CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
d Iherebyaffrm that therels a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z arm of the work!or which this permit hwyed(Sec.3097,Civ.CJ
U O anaera Na a i'/ 73,13
PLUMBING FEE
LL l— 1.cder's Address %a /r—d QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W l mrtifythatl have read thlsapphu onand statethatthsabovelnformution
N lsmr.ct.Iagree to comply withal]city and county ordinances and state laws I'QRMITISSUANCE FE [r� �
r relat oenterulpon the
mnstaHoryandhereby authorise rcpresenpurpos
F Z dt(Wa)aeree to the,Indemnify an d pmpectyfor
wteHon purposes. AL777(ORADD TOMECH. Date Recei t#
— (We)agree to pave,Indemnity and keep harmiess the ICityna of anyway
crus - P
againstliabilities,pdgmenta,cons dna expenses which may Inanyway acmaue AIR HANDING UNIT(TO 10,000CFM) SUBTOTAL:
against City In mneryuena (the anting of thio permit ./q/� AIRHANDUNGUNIT(OVERIQ000CF1. ) CONSTRUCFIONTAX
Signature of AInert/Contractor - /J Data EXHAUST HOOD(W/DUCT) C T CTION T�Jy{(�PAD:
HAZARDOUS MATER LS DISCLOSURE �Y (Q//
Will the applicant on future building oceupant store or handle havrdous HEATING UNIT(TO 100,0000T" I
Dale Rttei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the -
Iiealth and Sdety Codil
e Se .25531(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL'
❑Y. r]No
Will the applicant orfunim building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haurdous air contaminantsas defined by the Bay Arca Air
my Management District? BOILER-COMP QHP OR 100,000 BTU) iCpy�j
yc.
have mad the h.2us materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BN) FEB 1.41991
the California Health 6 Safety Code,Sections 29
lons 15505, 533 and 25534.1
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQJ7 r
rnpavibility to notify the occupant of the requirements which most be met ppI0��''
prior m issuance of a Certiflcateof mFancy. ya0v N14 ".w• -1
• /-i - 9a-
Pvncrora Iud agent Data ISSUEDr7
IOTA L:
OFFICE COPY