21703`.,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildimi-Pro'ect IdentificationPERMIT
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21703
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CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGS,ECTRICALPLUMBING-MECHAMCAL
A A A
1-9/
ContranorsName: Q Lir. No:
/t to -YAWf7
CATEGORY
CONTROL
Amhltect/Fsginesr. Lie. No:
QTY ELECTRIC PERMIT FEE
PFTMTISL ONCEj�/-
BUILDING PERMIT INFO
Addmss'.1401?/ ///j
PLUMB Mi�li
I �I
LICENSED CONTRACTOR'S DECLARATION
I herebyaffimmthat l am licensed under providonso(Chapter9(mmman
ingwlthSMlon7000)of Division 3ofthe Bualnessand ProfaW.n.Cod,and my
license 1, Infull Ioryg and died. y� 0
LicenCla.N
se s /3 LI�
APPLIANCES -RESIDENTIAL
- JOB DESCRIFTION
PANELS
Date Contractor
ARCHITECTS DECLARATION
I understand my planashag be used a public records
UPT02DOAMN,.l
201-1000A.MPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
��/ ?
SI'ECIALCIRCUIT/MIS
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Commences License law for the
following reason.(Section 7031.5, Business and Professions Code: Any city or
county which requires a permlttocomarm
re ucl, alter, Improve, deollah, ornpalr
(w_J '•
/JL
! o
TE]VIp,METERORPOLEINST.
anystmctvmpr rtoltabwancgaMrequlmtheappllrantforsuchperMtto
file a signed statement that he is licensed pursuant to the provisions of the
MOWER DEVICES
gWD.Mh9NG POOL ELECTRIC
Contractors License Law (Clapter9(mmmenclog with Section 7000) of DIN-
slon 3 of the Betaines and Pic esslona Code) or that he Is exempt th<rsfromand
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjectsthe applicant to a civil penalty of not mon than
five hundred dollars (SW.
❑ I, as owner of the property, or my employees with wages as their sale
OUTL7iTSSWITCHESFI%TURES
---
177
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, wnldothe work and thestroctum is not Intended or offered for
sale (i3ec. 7DI4 Bustin ess and Professlona Code: The Contractors License law
docs not apply to an owner of property who builds or Improves thereon and
who does sues
chwork himself or through his own employe, provided that such
OCCCROUP
RFS UNRS
Improvements am not Intended orof(ered for sale. If, howeveq thebuilding er
Improvement b sold within ora yearofmmpletlorc the cevner-budderwill have
TOTAL:
'
th rdenof proving that he did not bund or improve for purpose ofsale.).
1, as owner of the property, am exclusively contracting with Jimmied
contractors to mrutruct the project (Sec. 7014, Bin,mes and Professions Code:
Qry, PLUMBING PERMIT FEE
pERM177SUANCE
FLOOD WNE
APN
The Contractor: License law does not apply to an owner of property who
WBds or improve thereon, and who contracts for such pRajem with a
c71+nor(.) licensed punuam to the Contractor. License I.
LJ I am exempt under Sec. B A P C for this mason
ALTER -DRAM 4 VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR, ROOF, AREA, COND.
FIXTURES -PFR TRAP
SANITARY Y N�
RECEIPT N
Owner Date
WORKMANI have cartiTcateof CIARATION
❑1 hereby officers that I have o certificate of consent to pythemo ora
3BOD'LateofWorkers'Compenaatlonlnaurance oracertifled copy thereof Sec.
380Q lab CJ
SCHOOL TAX Y_ N
RECEJT T N
GAB -EA. SYSITM-1 INCA OUTLETS
PARK PER Y N
N
GAS PA. SYSTEM -OVER N (FA)
Conry ,
Company
DINCDI
BUILDING DI V ISION FEES
�❑ fled copy b bembytunecityished.
fied copy la (fled with the city inspection division.
GREASE/MDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
.
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssenion need nal be completed B the permit la (or one hundred dollen
PAID ��[( A -n
Date Recd t# /`- J`
SEWFR-SANTTARYSTORM EA 2DOFI.
(5100)oify that
Icethe workmnner for whichcels permit is issued,
thatlntheanypersoni
WATER I1EATTR W/VENT'/EECTR
ENERGYFEE Y N
not an
I shall not employ any person In any manner w ss to become wbjen ro the
Workca Compematbn hes o(GBfomla. Date
PAID
WATER SYSTFDM/TREATING
AppliNIDTICnt
NOTICE co APPLICANT: a cher making this Certificate of Exemption, you
should become evbjen to the Workers' Compenutlon provisbna o(the Lobar
Cade, you must forthwith comply with such provlaba orthla permit shall be
dedmed revoked.
Date Recel tic
NEW RESIDENTIAL PI -MB. SQET.
TOTAL:
BUILDING FEE
-116
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hemby affirm that them is a conatroction landing agency for the pedorm
anmofthework for which this permit Issued(Sec. 3M, CN.C.)
TorAL:
ELECTRIC FEE ,,,c4,
Lender'. Name .,�
hnaer.Aadmy �r7
] cerd. I hat I sfirm uti have readmla a pllcitlonat courts lhattbc cess iu Informationl.we
mrmct. Iagm to complywlth allcityaM muntyordlnannsand state laws
QTY. MECHANICAL PERMIT FEE
-dg
PLUMBING FEE �% ,4,p
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
matruNon, and hereby authorise t olmla
city to enterupon
citytope io purposes.
to the, indemnify snit pmpertyfor inape Cit of Cu pert
(We) agree to save, indemnify an d keep Farmies the City of Cupertlw
ALTER ORADDTO MECH.
Date Recei t#
P
SUBTOTAL:
agalnat llabilltic.,judgments, costs and expenses which may In any way s¢roe
agalmsaid ensu of the grant Ing of thls pemni
'
AIR HANDLING UNIT (TO 10,ODO CFM)
AIR HANINJNG UNTT(OVER 1QWOCIlf)
CONSTRUCTION TAX
Sign r Applicant/Contractor Dae
EXHAUSTHOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATINGUNITUO100,0001ITIn
Illtheappllcanl ce futum building occupant store or handle havrdous
material as defined by the Cupertino Mumdpal Cad, Chapter 9.12, and the
Date RCCCI !#
HEATING UNIT (OVER 1OD,000 BTU)
TOTAL:
Iiralth and Safety Code Section 25532(a)2
❑ Yd, M No
VENTILATION FAN(SINGLERESID)
RLS CE DATE
/`
Will theipplicant orutumbuilding.pantusecquiprrcnt ordevices
which emit hanrdous air contaminants as defined by the Bay Area Air
BOILER -COMP OFE'OR 100000 BTU)
Quality Managenrnt Distria7
4 Yrs I-1 No
haff.mi. mebaaar out maledab Chapter 6.95 of
t A1 7 1
f t4, 1 R 1991
OOILFR-COMP(OVER 1N,000 BTU)
me imei2rrcmtsundcr
nth Ficalm & Sa@tyCod, Smioa 75505, 25533 and 25536. 1
NEW RFSIDFNTIAL MECH. SQ.IT
understand
understand that iftletbitillding not herrcntlyhave a tenant that
responsibility to natty me occupant of the mqulmment. which asst be met
occupaea of b met
Prior m' a ofa Cenif co/Oavpanry.
/ y/Date
`j) qj Cnnn-+'nn
ISS .(.'rie"W(,LLt ,�a(��
rout veal agent
TOTAL:
OFFICE COPY