21837 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21837
'1 a� 6"1
//zOV,r�C IAANc- L>` G I VS
CITY OP CUPERTTN0.DUILDING DIVISION
,. Ccmh.dm',N.me: _ J,L,ic..No: APPLICATION / PERMIT
0B Jam/"/JCATEGORY C OLN
ArtM1lt �`neem. �/ BUILDINGEIECTRICALI'LUMBINGMFLFIAMCAL
Lk.Km
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrev:
LICENSED Rf 'S DECLARATION PERMITISSUANCE 3'
D-/
Ihb ftiamBcmsedurproonsofChrmAPILIANCESRESIDEMIAL
ingwithSH.n7000).fDiWalon3oftheBustn...ndPofY..C.d,a.dmy JOB DESCRIPTION ESCRITION
license Is In full
Lfo d effect. ` PANELS
lcenscChx LIc.N
Date Contractor —UP TO 2DO ANTS
ARCHITEC9•S DECLARATION 201-1000 AMPS
ce C70C Iundeetand my plase
rusluil beud as public.,d,. OVER1000AMPS- SQ.Fr.FLOOR AREA $/SQ.FT.
bU Licensed Professional SIGNS ELEC Z7/y
�<FA OWNER-BUILDER DECLARATION evFr'taLCIR -
T/MIST
6.�Z IherebyafRren that l am exempt from the Contractor's License Lawforthe
Z following reason.(Section 7!315,Business and Profession.Code:Any city or u e 1
�qq�yy mon hlchre I mittomms altegim demollsh,ormNir TEMP.M RIi' 97.
�`�a:a anysttrructure prorto its U rnce,also requlresthe applicant forsuch permit to
file.signed statement that he isIlcensed pursuant to the provisions of the POWER DEVICEATE
3 u'G
Contractor's License Law(Chapter 9(mmrrcntlng with Section 70M)of pW- SWIMMING(VOL ELECTRIC
slon3ofthe Buav
lneandProfesso
imuCde)mthat hetsexempttherefromand VALUATION
r�6.51 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWHCHES-FI)< ES �fJ// �
applicant fora permit subjectsthe applicant too civil penalty of nee more than (��
c.
five hundred dollenhepro - NEW RESIDENTIAL ELECTR SQFI. SNAILS TYPECONSTRLCTION
k 6 ❑I as owner will
o t property,or h, employees with wages r thele sole
compensation,willdothweak,!Prof l..Cccturch rotIntended oroffered for
O sob(nce.Z0µtoBin.inessi
own M fprope property
Co Wilds Contractors License Lw
(rj$$ docs not apply torn owner or throng hiswho
nempor imprwvided that such
OCC.GROUP RES.UNITS
C.
who does msuch
ntsworkMmse f or intended
hisownemp,yees,hinve proei,thebuildi nor
improvements arc not Intended oro(fcrtd foraale.If,howeveq thebullding or TOTAL:
improvement lsso41 wlthinoneycarofcompletbgtheowner-bullderwal have
th rden of proving that he dm notWildorimproveforpurpoacofask.). QTY. PLUMBING PERMIT FEE
FLOOD LONE APN
Lj S err owner tr the property,am exclusively contracting with licensed PERMIT ISSUANCE
TheconContraction's
to construct the w doe(Sec.apps Business and Pf property
Cede:
The
Cantrampro es Cher Law dm eat apply to an owner p property who ALTER-DRAIN Is VENC-WATER(EM
Wil or improve thereon, and who contracts fee such plojem with. FEE SUMMARY
,➢2�actar(a)Icenad pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this mason
Ql1TqinP Err,
DRMNSFIOOR,ROOF,AREA,COND. SANITARY - Y_ N_
• Owner Date AFL®PI'N
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have o mrtiflaite,ouranc of consent to copy thereof
ora RECEIVE N
certificate o(Worken Campewdon lnsuran�emacedl(led mpythereo((Sec. GAS EA.SYSTEM-1 INCA OUD,ETS PARK FEE Y N
38m,Lab CJ
Policy N GAS G.SYSTEM-OVER a(FA) RECE1Pr N
Company BUILDING DIVISIONFI:1:5
[ crtlBed copy is filed with C Bed copy lsrc
hereby the the city ty Wpectlon division. GREASE/INDUSIRL WASIR INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE S5�
Dale Recei 1#
(Thissectlon need not be completed if the permit b foram hundred dollar SEWER-SANITARY-STORM EA.2WFT.
(flmrifyt3 t
ceWATER HEATER W/VENT/E-ECTR ENERGYFEE Y N -
Irt less.)
pedomunceafthe work forwhkheNa permit Issued,
shall not employ any person In any manner ao u to become object to the WATEt SYSl41/IREATINC
Workers'Compensation Laws of California.Date PAID
—
zZ Applicant NEW RESIDENTIAL PLMB. �F<. Date Recei (#
Z O NOTICETOAI'PLICAM':U,.A,rmakingthls Certlflcateof Exemption,you
ahmld become subject to<he Warken'Compeuuatlon provlslov of the Labor TOTAL:
~ N Code,you=at forthwith comply with such provisions orthls permit shall be BUILDING FEE •Ser
I' `> dmmed revoked.
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE eOZ
a Ihereby afflrrn that there ls.mrulmction lendingagency for the perform ELECTRIC PEE
M = anceoftheworkforwhlchthlspermitls�p ed(Sec.3097,0e.C.) TOTAL: .1�
U O Lender'sName �N n PLUMBING FEE 70.7r
LL F Lenders Add ra, " QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO Is c l cedlfy thatl have read this applicationand statethatthcabovcinfornution
LLJ rmct.(agree to complywlth alldtyand county ordlnanmand state lawsPERMITISSUANCE FEE
Mrelating to building construction,and hereby authorize representatives ofthisIn
F Z city to enter upon the above-nentlomdpropertyforlmpectiunpurposes. ALTERORADDTOMFCH.
_ (We)agree to rave,Indemnifyon d keep harmless the City of Cepertlno Date Receipt#
against lirbll ma'cee aexpe sea which myln any wry acwe AIR HANDLING(1NTT(1'010,000 CFM) SUBTOTAL: q
againsts nrequ he s�'ng dthle pertnB. 9 AIR HANDLING IWIT(OVER IQ000CFM) 'CONSTRUCTION TAX �SO�
Signaty Appian Contract« to EXHAUST HOOD(W/DUCT)
C /y {)CYTON TAX PAID
HAZARDOUS MATERIALS DISCLOSURE 9�
Ill the applicant or future building occupant store or handle hazardous HEATING UMT(IO IM,(UO BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the - p�
Ilealthand SafetyCode Section 3553200? HEATING UNIT(OVER 100,000 BTU) TOTAL-
El Ye NN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hairdous air contaminants as defined bythe Bay Arca Air pass w►
• Qu Iity Management District? BOMER-COMP(3111'OR 100,000 BTU)
4Ye nn No
havereadtM1eha am. muterlalsrepirementsunder Chapter 6.95of BOILER-WMP(OVE im'"BTU) F�� 141991.
the Glifomia Health k Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MEIN. SQ.Ff '
rmporuibllitytonolif th pantoftherequ lecnents hlch mustbe met
prior tol t Oavpanty. ) �s ( N}riffr' '-1
Owneror zedagent Date TOTAL: ISSUED BY: e
OFFICE COPY