21741 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin No'ed Identification 7 PFTLWT NO.
Building Address: r)
!i786 v„,f /-0rT 21741
• a
APPUCAIIUN nUtIM11 IALA
ner QY + CITY OF CUPERTINO-BUILDING DIVISION
Na LO� r7y I PERMIT / — 2-
APPLICATION
0 BUILDINC-ELECTRICALPLUMBING-MECHAIICAI CA D ARY CONTROL N
it /Engin er
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO _
Address: PEMTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hererm that)amlicensed under provisionso(CAPPLIANCES-RESIDENTIAL
JLX
'nSection7000)of Division olthe BusinessandPm(essforsCode,and my
license 1slnfull fo and effect.
JOB DC9CRERTON
[/ /g) PANELS DLO
License Class L,,.,_ a[�O`/ ��
Dao Contronhador ' UP TO 200 MVflS
ARCHITF.CPS DECLARATION 211-1000 AMPS
reoz Iundentand my plans shall be used as public reards. OVERIODOAMPS SQ.F7.FLOOR AREA $/SQ.FT.
2 Fj Licensed Professional SIGNSELDCTRICAL
< OWNER-BUILDER DECLARATION a! I:J •' li
7t, 7 Ihereby affirm that l am exempt from the Contractor's License law fm the 9aECIALCBtCNT/MESE
p following reason.(Section 701.5,Business and Professions Code:Any city or K�
O]1- TEMP.METERORIOLEINST.
F� county requlreaa permit ronstauirestheaprovydemolbh,orto
a
anyatadure paler ent•haae L,alw requ pursuant
ttothe for such
ro,ofpermit e POWER DEVICES
IIIc a signed statement that he ls Licensed pursuant to the provlsbns of the
�3 G Contractor•License Law(Chapter 9(mmmenMgwlthSection7(XD)ufDivi- SWINMNG C
t-Et sion3ofthe Buslnessand Pao(e.W.Code)orthahelsexnmptthemtmmand VALUATION
g �'•.1 the basis for the alleged exemption. Any violation of Section 7MI-S by anyOUTLETSSWf .
� 3<5. applicant(orapermitsubitetatheapplicantin-civilpenaltyofrctmorethan
m five hundred dollars(S500).
NEW RES Dkdivll�scu
?a �I,as owner of the property,or my empbyen with wage as their sole STORlrq TYPECONSITtLCT10N
mmpenotlon,w0ldolhe wok andthe structure lsna Intended or offered for
O rile(Bee 7066,Business and Iarof<ssbns Code:The Contractors Llceae Uw
does not apply to an owner of property who builds or impaovn thereon and
c. whodonssuch work himself orthrough his own emplprovidedFSM
ces,provided that such OCC.GROUP RES.UNITS
improvements art rot Intended oroffered tarsale.If,however,the building or TOTAL:
improvement issold wlthinone,yearofcanplelion,theowner-Wilderwlil have
t"aden of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE ROOD ZONE APN
L j 1 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mnswct the preset(See.7M6,Business and ProfessionsCode:
The Cont.dori Llan.Law does not apply to ertyan owner o!propwho ALTFTt-DRAIN&VENT-WATER(EIV
Wild• or imprwe•th...and who contracts for such pip)q with s
,Ltra ...)licensed panaam to the Contrador'.License Law. FEE SUMMARY
U I am exempt under Sec. B& P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
Owner Date BBC=aWORK MAN COMP F2JSA3'ION DECLARATION FIXTURES PER TRAP S Il LTAX Y_ N
❑I hereby affirm that I have certificate of consent to.](.hare,(Sa RECErr a
3500,labb C.) S W
artlflcaC(Worken Compensaionlnsuranmora arti(led rom
pytheof(Sec. GAEA.SYSTE?A4 CAOUN_TLETS PARKFEE Y
Ibliry N I
GAS EA.SYSTEM-OVER 6(EA) RECEIPT N
Com!ny,n / /G/ !`__ BUILDING DIVIBION FEES
91CertlBed copy ls herebyfurnished.he cit. - -
CertlOedcopy lsfiled with the city inspection division. GREBE/[NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF FXEMITION FROM WORKERS' GREASE TRAP PAID
INSURANCE
NSURANCE SEWEILSANITARY-STORM EA.2IXIFI. Date Recei t# Sa
(fhisuctlon need out be completedpermit ls(erectshundred dollars
(fl00)^r lex.) WATFRIIFATQt W/VENT/F],ECTR ENERGY FEE Y N
notify rtify that In the performance of thework forwhlch this permit is 4aod,
Ishall no employ any person In any manner an as to became subject to the WATER SYSTEM/TREATING Workers'Compcnsation Tawsof CAl/orals. Date PAID
O Z Applicant NEW RESIDENTIAL]'LMB. SQF7. Dale RCCeI t#
Z O NOTICE TO APPLICANT:IT,after nuking this Cedtfleate of Exemptlan,you
Hshould becomesubjed lathe WorkersCompensation provisions ofthe Labor TOTAL:
CC W Code,you must forthwith comply with such provisions or this permit shall be BUILDING '
jdeemed revoked. '
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Hureby affirm that there is a mmtmctlon lencileg ageng for the perform. ELECTRIC FEE
Z anccoftheworkforwhlchthlspermitlsLs d&$ .3097,CIv.C.) TOTAL:
00 LoArr'sName PLUMBING FEE
LL l- I.cnder§Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iartlfythatlhave readthlsapphcalion and eta tethattheaWvrinformatlem
C iscomet.I agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES / � /-
relatingtobuildingmrutrudlon,and hereby authoare representatives ofthis
F- U) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Recei [#
(We)agree t^saw,Indenify as d keep harads.the City of Cupertino P
V ag.l.st lbbilltics,judgmcnts,mrts and expenses which may In anyway aceae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In ansqueme of the granting a this pe t.
\\ p ” AIR HANDLING[ATT(OVER IO,000CI]vI) CONSTRUCTION TAX f
C d. 1-h Oln ` � F.
Slgnamreo(Ap Il HAZARDOUS {1' ?te EXHAUST HOOD(W/DUCT) COf17$7f CTION�/y)C ID:
HAZARDOUSh ATERIALS DISCLOSUW: / 9/.
Will the.pplIcant or future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU)
a aterulasdefinedbytMCupertlno Municipal Coda Chapler9.17,andthe Date RCCCI t#
I loalth and Safety Code Section 2553](x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
a
F-1 Y. M No
Willtheappllcant or future Wilding occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hava a.a air contaminants as defined by the Bay Area Alr
I * Quality Management Disldtt7 BOILER-COMP(3HP OR 10,0(0 BTI) I-Alan
Yo FF�� aNo //www
have read the haze`rJu materials requirements u nder Cha pter 6.95 of BOILER-COMP(OVER 100,000 BTU) FEB. 1 4 1991
the Glifornla Health&Safety Code,Sections 75505,75533 and 75536.I
understa nd that if the bu ild Ing does not currently have a tenant that It is my NEW RESIDENTIAL MECH. SQ.FT.
raipoauibility to notify the occupant of the requltements which must be met r
Prior to issu n1a ofpp.Certificate ofocrupamy. psi Nunw �,,
`/�1 JJ kn - �• S ) 3
Ownero>F.Wh6riud agent Mats TOTALISSUED BY:y1_
: —
OFFICE COPY