21294 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
r 3nlldl"4 Noted Idemiflcation PERMITNO.
BvIldfng Address:
21294
l 2 �e{�Svs' z�cG CUL .V�dvs. �
^ynere me, one: AL DAM
011 �H (!1 LS_ etl CITY OF CUPERTINO-BUILDINGDIVISION
C.Mracto".N.me: ek.Na: APPLICATION I PERMIT
BUILDINGELECnUCAI hM
.PLUMBINCECHAMCAL CATEGORY CONIROLY
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address O PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION o(ChON
I hereby edtonmthatlamdon3ofhe under Busi andPoffnsimsr9(mmmmc APPLIANCESRESIDENTIAL JOB DFSCRII'ITON
Ingwe 1,1.
full to=o!d effean3oflhe Buelneavandl'mlodonvCode,end m
license lelnfu8(orae and effect. PANELS
Licen.c Clam Lk.Y
Date Contractor UP TO 2DO ANTS
ARCHITECPS DECLARATION 201-1000 AMPS
Ore 2 I understand my plans shall be used as public recon.. OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.FT.
0C
zfi Licensed Professional SIGNSELFCTWCAL
�ald OWNER-BUILDER DECLARATION SI'ECIALCB2CU[T/MISC
Ihereby affirmthat Iamexempt fromtheContractor'sLicemelawfmthe
Q following reason.(Section 7031.5,Business and Professions Code:Any city or
y county which requires a permit to mrutmct,alter,Improve,demolish,or repair TQ.IP.METIA ORI'OL MSI.
anysmacNre prior to lb Issuance,aborequirea/he appUmet forsuch permit to OWER DEVICES
(� file a signed statement that he Is licensed pursuant to the provisions of the
3w�
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOLCTRIC
si.n3.fthe Business and Profewiou Code)orthat hell exempt there(romand VALUATION
5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSMTC Fl
applicant for a permit subjects the applicant to a civil penalty of not morethan OW Vll
1 e undyeddollars
owner of the
property,or NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
�n as ro
c neation,wBldothe work endthe employees with wages as[herr sole atudure besot lnlended or offered for
Onate(Sec.7044,Bu.bc..and Pmfeviau Code:The Cordmd.e.Lt..law
$$ does not apply to an owner of property,who builds or Improves thereory and NxaOCC.GROUP RFS.UNITS
who does such work himself orthrough Ms own employee,provided that such
Improvements arc not Intended oroffered forsale.If,however,the building or AL
Improvement h sold within aneyearof completion lM owner-bullderwlll have
llLJ L Iden of proving that he did not build or Improve forpurposeo(saleJty
. Q , PL PERMIT FEE FLODDZONE APN
as owner of the property,am exclusively contracting with limned PFAMLL ISSUANCE'
contractors to construct the project(See.7044,Business and Professions Code:
The Cmarach rb License law does not apply 10 an owner of property who ALTER-DRAINk VENT-WA
Wild. or Improves thereon, and who conenda for such p(uleca with a FEF.SUMMARY
cgp(tador(a)licensed pursuant to the Contndoes License Law. BACK FLOW PROTECT.DEVICE
LJ I am es i d Sec. B k P C for this reason
OUTSIDE RES
,,.�,.j,,� DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
Owner ` Dared RECRUIT
4) certificateWOR fPIT15AT10N of
to ptt. ps PER TRAP SCHOOL TAX Y N
Of hereby orke ve•cesuranc of consent to opytnrom,or
RECEIPT#
3800,Lab C.Workeri Compeuatlonlnsurance oraortl(ied mpythertro((Sec. GAS EA.SYSTEM-1[NC.40UTL PARK FEE Y N
Polis Lab CJ
Paltry# GAS.EA.SYSIFM.OVER 4(EA) RECER''f.p
Co any - BUILDING DI VISION FE ES
ffc,,Y Nmpy t+hemby fumlehcd. CREASE/INDUSfRL WASH-INTERCEPTOR PIANCHECK FEE
OCertlfied copy b filed with the city inspection division.
CERTIFICATE OF F7(EMP11ON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.20011r. Date Recef i#
fThi.sodian need not be completed If the permt,for one hundred dollen
(SID0)mlees.) ENERGY PEE Y N
Imrt(fy that In the perfmornomofthe work for which this permit,blued, WATER HEATER W/VENT/ELF-CTR _
f shall not cm 2 t e on In an manner so u to be ro the WATER SYSIGI/TREATING
Worlicant o pen ten Tomb.Dam PAID
O Z Applicant 0 NEWRESiDENTIALPLMB. SQRT. Date Recei t#
Z O N07TCE TO AI'PL T: rmalung this Certi(lote of Exemption,you
should become sub orken'Compensation provisions of the Labor TOTAL:
N Code,you muss fort hwith comply with such provisions or this permit shall be BUILDING
W �
> deemevo
ed rked.
UjCONSTRUCTION LENDING AGENCY SEISMIC FEE 8
I hereby affirm that there is a coutrvdlon tending agency for the perform ELECTRIC FEE
Z saw of the work!or which this permit b bwred(Sec.3097,CIv.Q TOTAL
(� O Lender'.Name PLUMBING FEE
IL tender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Imdifythallhavemadth(sapphottanand Catelhattheaboveinfomution
O W
a Is mrmd.I agree to comply with all city and county ordinances and Mate laws PERMITISSUANCE FEES PAID,.
} N rebttngt.b.ildingcomtmdimind Mmbyauthodaampresentativesofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. Date ReCCI i#
(We)a to five,indemnify an d keep harmless the City of Cupertino
V agalnstB nts,mksand.:pensee whkh may res anywayamrue AIR HANDLING I1Mi(f010,000 CFM) SUBTOTAL'
agabut sal uym the granting of this perm . AIR HANDLING UNIT(OVER IQODOCFM) CONSTRUCTION TAX
c to
SlgnatureofA 11 ,t tractor Otto IXHAU5THOOD(W/DUCT) CONSTRUCTION TAX PAID:
A OUS MATERIALS DISCLOSURE
Willtheappllontorf w.building.pantstomorhandleh=ardous HEATING UNIT(TO 100,000 BTU) Date RCCeI 1#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand SafetyC Ion25532(a)7 HEATING UNIT(OVER 10,000 BTU) TOT�A.�L:. x
Yes No
Wllimr applleantr reumnang as dell edi by the Bay Area
devisee VENDLATIONFAN(SINGLE RESID) !SSU
which emir havrdous air mntamlnante as defined by the Bay Area Air
Quality Management Drs rid? BOILER-COMP EIHP OR 100,000 BTU)
4YceNo OCT 26199(�
haiforead thehas oety Cutch Section 25505,under Cha 4. 1 of AOILFR-COMP(OVPR IO,000BN)
the California Health&Safety Cade,Sections 25505,25533 and 25534. 1
understand that 3010.bulldingdoan of to requirements
tenant=at It met NEW RESIDENTIAL MECH. S(J.FL City YI Cupemno
ropoulhl nail the ocmpa est of the mquircmente which must he met
prior to lssu ce IcateofOaupanry.
a
Ownerorauth rl ag est D#1. ISS(IEDBY: yl V 1..7`0 Aa'-w�
TOTAL:
OFFICE COPY