21252 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Ponied Identification PERMIT NO.
Bulldog Addre.e: 21252
�lS AZZW w ;sw
wa one: AL DA IE
a CITY OF CUPERTINO-BUILDING DIVISION
con ttor'sNa I Lc.No: APPLICATION /PERMIT
Archltett/Eng) ares Lk.N BUrLDING.ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL M
QTY ELECTRICPERMIT FEE BUILDING FERMITINFO
Address:
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION 154.
Thereby affirm that l em licensed under Provisions of Chapter9(commune. APPUANCESRESIDENT1AL OB DESCRIPTION
Ingwith Sedion7000)of Divblon3oftheBminessand Profeul Cod my
Iicenes ie In(uB sand effect O /'� PANELS f
Date Clam U LIeM e7
ate�AContrattor ;je Or,To
��/�• RCHITE I
2U1-1000AMPS
03 I understand my playa shag be used a public mmrds. OVER 1000 AMPS SQ.FF. R AREA $/SQ.FT.
ZLlcenmd Professi.nsl SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M
I hereby affirm that T'am..rmpt from the Cortradm'.License Law fa the
pp tK
following ressun.(Section7031.5,Businessand Professions Code:Anycityor
I
F � countywhich requlmapertNtrommtruct,alter,impmve,dennl6h,orrepalr TEMP.METERORPOL
$ anystructure prior to its hasuance,alsorequlreslhe appliantfor such perndtto POWER CES
{?O file a signed statement that he is licensed pursuant to the provisions of the
R w C..1-coo.License Law(CFapter9(mmmerengwith Section 7000)ofDivi."'30 slon3 ofthe Business and ProfeulOv Code)orthat he h exempt lherefromand SWIMMIN POOL G C VALUATION
Fa 4 the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7Lr IS5 TC ES S Q
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars(;500), NEW RESID ALEL SQFI. STORIES TYPE CONSTRUCTION
�n ❑1,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the strocture he not intended or of(emd for
JO sits(See.7064,Business and Professions Code:The Contractors License Law
cj $ does not apply to an owner of property,who builds or improve thereon,and OCC.GROUP RES.UNITS
CC.• who domieech work himself.,through Maros.employees,provided that such
improvements are not intended oroffered for sale.If,however,thebuilding or TOTAL:
improverreco old within oneycarofcompldiontheowner-builderwill have .
IIe.hurden of proving that he did net build or improve for purpose of ule.). QTY. PLUMBING PERMIT FEE EL5OD7DNE APN
U 4 as owner of the property,am exclusively contracting with ouenrad PERMIT ISSUANCE
contractors to construct the project(Sec.7064 Business and Professions Code:
The Contra tor's License Law does nest apply to an owner of property who ALTER-DRAIN&VENT--WATER(EA)
builds or improves thereon,and who centrads for such Ptojette with a
cgRt7�togs)Oansed pursuant to the Comrattoh Linares Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I ec am exempt under SB&P C for this reason '
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECFLT-
WORKMAN DECLARATION AN COMPENSATION
[:]I hereby affirm ceconsent I have a rtl0of connt<o selbareFIXTURES PER TRA]' SCITOOL TAX Y_ N
tr ,
,or RECEIPT N
3800,Lb CJ
certfica
ite OfWorkers'Com tlonrns ranre on certified copy[heruof(Sa. GAEA.SYSIUA-1 INCAOIITLETS PARK FLT? Y N
7 n
S
Polley M � a+' �� '(! RI:CEII'T M
CGAS FA.SYSITM-OVER
BUILDING DI VISION FRTSmCertifed p e f
she city CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Certified copy h(Ikd wit thinspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE, SEWMR-SANITARYEA 20OFT Date Recei t#
Clhlseectian need not be complied If the permit lila one hundred dollars
(5100).rlesvJ WATER HEATER W/VENT/ELHCTR ENERGY FEE Y N
I certify that N the performance of the work for which this Permit is hard, —
I shall not employ any person In any manner so sit to become abject to the RIOTER SYSTEM/TREATING
Workrri Compenutlon Gws o(Califomla.Date PAID
Z Applicant
Z NOTICE TO APPLICANT.It,cher making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFr. Date Recel t#
HW
should hemeaubjrrt to the Workers Compensation provisiom of the Labor TOTAL:
CCode,you at forthwith comply withsuch provisions or this permB.hall he
j trained oked. BUILDING CYl
amrevG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyiffirm that there is a censtection lending agency for the perform- ELECTRIC FEE Q
Z ance of the work for which thus permit is Issued(Sec.3097,C Iv.C.) TOTAL:
V O Lender's Name PLUMBING FEE
LL F lerd,e.Addreae - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I aabove
rtifythat l have read thisapplicattonand statethat the information
Is cones.L agmato complywithall City and musty ordinances and state we PERMITISSUANCE FEES PAID:
} (L relating to building construction,and hereby autho be representatives } Is
F N citytoenter ntheabove-mentioned property far Inspection pu seX ALTIRORADDTOMECH.
Z �e Date Recei t#
— ;t .)
a e to eve,Indemnity an d keep her the City rtlno P
agalestll IIIHss,udgments,cestsandexpense Ich may In yaceme AIR HANDLING UNIT HO 10,000 CFM) SUBTOTAL:
ago' dei Ism !q..e hegranof this pe
n AIR HANDWNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S gwture.(Applicant/Contractor
Gulf ExHAus r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATEitJ/ DISCLOSURE
Wllltheappli storfutumbullding pant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCe] t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the
IWIthand Safety Codi,r.-S�ecilon2S532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
f7 yes
u No
Will the applicant or future building occupant use equipnant or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defirad by the Bay Area Air - 1'
Ilty Management Distrit2 BOILER-COMP QHP OR 100,0(0 BTU)
❑ �1 Y
Yea No
have read the h.zaN ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Code,Sections 25505,25S33 and 25536.1 �_„rasbTp
underst.nd that if the building does not currently have a tenant,that it h my NEW RESI DENTIAL MECH. SQ.FT.
responsibility t.notify the occupant of the requirements which must be met
poor toissuance ofaCertificate o!Occupancy.
Ownerorauthodzed agent Date TOTAL: ISSUEDBY:�ja,�
OFFICE COPY