21890 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification - PERMIT NO.
Building Addmae: 21890
Za.ZoS Aye- L t L ;
ane: APPUCA RON SUBMITTAL
-SU„I fif e V P CITY OF CUPERTINO-BUILDING DIVISION
cwt 'otor Na : Lie.No: APPLICATION / PERMIT
I•SZtr
ions BUILDINGELECTECAI.PLUMBINGmECHANICAL CATEGORY CONTtla i
l
rchited rt� Lie.No: 10 S
V — '` - - BUILDING PERMIT•INFO
- �• G
QTY EGECTAIC-PERA'fIT " FEE
A 'T110 -✓` -J� PERMITISSUANCE �2„pD 1 � (Q
LICENSED CONTRACTOR'S DECLARATION a �T LFJ'
Iherebyaffirmthat l amlicensed under provislonsof Chapler9(mmmene. APPLIANCESRESLDENTIAL JOB D75CIiEs'fION
tngwlth Sedion7lBU)Of DiWslon3ofthe BusinessandProfesatons Code,and my f'� ES RIPHO
license ism fun tone and after. PANES ��Y L 12 5�6-woLifteData
mdr lass L 1
Date Contractor UP TO 200AMPq
ARCHITECT'S DECLARATION XII-lfgO AMPS
rcOz I understand my piamahan be used as pubic records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O 1
L Fj Licensed Professional SIGNS ELECTRICAL `�l�"� A3 ^`5.oo
6 ° OWNER-BUILDER DECLARATION - BPFGIALCIXCU[T/MIST I `b I Lyt %2—
7F, I hereby affirm that Is.exempt from the Contractor's License law for the c l
following reason.(Section 70315,Business and Professions Code:An d r
O t. Y city TEMP.METER ORPOLE INST. ��f -
K� muntywhim requlroa perradttoromtmuices theaprovantfor ich,ormpairmarto b
g anyswdureottemepriorto lb Issuance,abo sed Pursuant
to
provisions
of dte POWFADEVICES C
F rNE � the a algned stawment that he b licensed pursuant to tM provblom of the
Q63u, do
Contractor's License Law(Chat pter9(commencingwlthSectlfD
on7DOO)oivl-
O G SWIMMING TOOL ELECTRIC
I„m�s slon basis fo the alleged
Any violation bexempt therefrom and
VALUATION
the Wan for the alleged exemption. Any violation oenadbn 70315 by any 'b A
five.hundred
dollars($500).
the applicant t°advll penalty of nor more than UTT•EISSWITC}[ESFlXT"(1RFS V L
Q five hundred dollen($500). � � � �,q 6�
u• co
NEW RESIDENTIAL ELFLTR
p, �1,as owner of the properry,work,a or my employees is act
with wages r there dole --�' ' S'�R�S a� TYP�CONSTRUCTION
rompensatlon,will d°the work and the structure br�ot intended or offered for N A E
Cl sale(Sec.70K Busmessand Profession Code:The Contradors Llcemelaw
$ does not apply to in owner of property who builds or improves thereon and
a who does such work himself orthrough his own employees,provided that such
improverrcnb arc not intended proffered for sale.](however,thebullding or TOTAL: , � OMP
Imp. menl bsold wltMnoneyear°fcompldlon,the owner-bunderwill have
tlill.�uNen of provingthat M did na build or improve forpurpose,ataxia.). QTY. PLUMBING PERMIT FEE p
7 lie 41
LPW
contr I,as owner of the property,am exclusively Business
and Pro with licensed PERMIT DANCE P] monamom
The Contractor's
act roavt. the probed(Sec apply
to ness and Professions property
Code: V
Wil Contractor's Limrue law does h apply to an owner M Property who ALT-DRAIN k VENT-WATER(EA)
o9wa or Improvus thereon,and who centrads for such plo)eds with a Z_ 0
anp(pdmexe must plunder Sm.nt
the ContradoYeLlre,P Law. BACK FLOW PROTECT.DEVICE FEE
CUSTS UMMARY
FL
I am exempt ober Sec. B&P C for this reason
I - DRAINSFLOOR ROOF,AREA,COND. SANITARY Y N
Date
Owner RET- N
WORKMAN COMPENSATION DECLARATION FIXTURES—PER TRM g. �u SCHOOLTAX Y N
❑1 hereby a(lirm that 1 have o ce xaminc of°°resent to opfdnsure,oracertifiRECEIPT M
3800,Lah o(Worken'Compematlonlmunnce orarertilled copy thereof(Sac. GAS EA.SYSTEM-1 INC ODTLM PARK FEE Y N
Policy
lab CJ
Com an - GAS EA.SYSTEM-OVER4(EA) DING TM
Y BUILDING DIVISION Ef:f:S
rti0ed copy b hercbyth the city CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
entified copy b(lied with the EXEMPTION
FROM
division. �\�
CERTIFICATEMPE SATI N INS ROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
IThb sedlon need not be complded lithe permit b Torunn hundred dollars SEWER-SANITARY-STORM EA TOOFT Date O Re 1 of O0
($100)°rless3 WATER HEATER W/VENT/ELECTR ENERGY FEE
I certify that In the person in an the wmksfor
as to b corn permit abject
tothissued, —
I shall not employ any person In any manner n m to become abject mthe / WATER SYS EM/TREATING . 0 U PAID
-
Z
Compensation laws of California.Date II Q^
Z5 NOTlicant
ICETO APPLICANT:If,ofter making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFT. Date I.cel tk e!L�
Fshould beromeaub)ed to the Workers Compensation provisions of the Labor TOTAL:
N Code,you at forthwith comply Mthsuch proWlom or this permit shall be
Uj j deeed revoked.
ac mCONSTRUCTION LENDING AGpNCUN Y SEISMIC FEE
I hereby affirm that there i e ermtmdlon lending agency for the pedorm ELECTRIC FEE
7 Z once ofthe w°rklorwhich this cu
permit Issued(See 3097,Civ,G.) TOTAL _00
U O Lander.Name PLUMBING FEE- - pp
LL — 1<nice.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W _ Irertifythatlhavenadthlsappncatbnand nate thattheabove Information -
tscorrcd.lagreetocomplywlthalldtyandmunty°rdlnanmsandtlatelawsPERMIT ISSUANCE Z.dU FEES PAID:
>. O" ral.tl.g to building romtmdlon,and herebysuthoriu representatives°fthb
1.- 0 city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. DO
_ (W)agree to save,ind iffy an d keep harmless the City of Cupertino - Date Receipt#
gait set bill pdgmenbco ander seswhshmayinanywayaccme AIR HANDLING UNIT ITO Io,ODOCFM) SUBTOTAL: 1.. .
I s d in inns yu nce sf the gra Ing oft a rm
s,p a AIR HANDLING UNIT OVER IO,ODOCFM) CONSTRUCTIONTAX
Signature of Applicant/Contractor / Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tk'
material as defined bN
y the Cupertino Mucipal Code,Chapter 9,12,..d the
Ilm❑lt yea and Safely Code
�-S,Lection 255326t)? HEATING UNIT(OVER IOD,000 BTU) TOTAL:
No 723Q�W
Wllltheapplicant or fu lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which em8 hard rdous air cents Mnanls as defined by the Bay Area Air PA=
Management District? BOILER-COMP 0HP OR 100,D(U BTU)
❑ Yrs No
7haveri.11heh &vf,4y ateriabrcqulrementsunder Chapte .I of BOILER-COMP(OVER 100,OW BTU)
the Gltand taatIfthOa Safety Code,Sodium25505,ve a tantl Xi534.1
understand that noillyheocupanhe building t note cureartly (hatb bmy NEW RESIDENTIAL METH. SQ.IT.
rcspomibtu issuance
Cemaavpantof ccepanequirerrcnn which must be met '
prior to issuance ofd Certlticate ofOmpancy. of c p `•.RV^w
r
Owner or authorised agent Date ,t ISSUED BY:'
/1 w
TOTAL: V """YY9--- -
OFFICE COPY