21745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification TI �Y -� PERMIT NO.
B°"ding AEdR", l� 21745
1 � `� 4 Q tort C_a.ct.,,L.C�1QIc— Cin r Lr1
era �. one A A A f-610af CITY OF CUPERTINO-BUILDING DIVISION
Tract. Na : . r� Lic.N . APPLICATION / PERMIT
C' BUILDING-ELECTRICALPLUMBING-MECIEAMCAL - CATEGORY CONTROL M
• chltm gine .v ' ;�
C Qn ELECTRIC PERMIT FEE BUILDING PERMITINFO
Address:
PERFBTISSUANCE
LICENSED CONTRACTOR'S DECLARATION -
IhembyaFEX
ffirm that[am licensed under provisions of Chapter9(mmmenc- APPLIANCESRESIDE.NDAL TOB DESC ON
Ingwith Senbn7000)0/DlNslon3ofthellusiressard Profes'socesCode,and my
L Anse Clarlicense s in R r L!N L�- 36 9 T PANELS
Date Contractor l'V
ARCHInCPS DECLARATION 201-1000AMTS iYY�
�7 l understand mype usea Public mror
lamshallbd blida OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ-17.
O
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SI'EC7ALCBiCUIT/MISTS
P, IherebyafRrmlhat l am exempt from the Contractor's License lawforthe
Z D following ream.Section 7MI5,Business and Professions Code:Any city or QOC .✓
O L I-u9 TEMP.METER OR POLE INST.
rmu
./
5 ntywhlch requlreaa permit tomnstruct,ilter,lmprove,demolbh,or repair
11 � anystmaartprbrto lTSBsuance,cels°mqulmtheappBontlm such permit t° POWER DEVICES
C s.5 file a signed statement that he Is licensed pursuant to the provisions of the -
w Contract./,License law(chapter 9(commencing with Section Mid Divi- VALUATION
Ot' sion3ofthe Business and ProfessionsCole)orthat he h exem therefromand SWIMMING IDOL ELECTRIC
Qa the Want for the allegedpermit
%o exemption. Any t toa ioncivil
d natty Of not ex b3'any OUTLETSSWITCI-DSEXRTRES /�� /
C
applicant hundred
redfor aper dollars,
j. the applicant Toa dVil pevlty Of not rromtlun
P. O� fivchandmdddhmhepr.
R_ NEW RESIDENTIAL ELEC STORIES TYPE CONSTRUCTION
I,as owner o/the property,or he employees in with wage as thele role
k7a compensation,will do Businessawork.andtheCde:TheCs not ldende,License for
Law
S�❑ sslc l.Eec.7004 Business and Professions Cade:The Contractors License Taw
( $$ does not apply loan owner of property who builds or improves thereat,and \ MOCGGROUP RES UNITS
C whodoessuchwork himselforthrough hisownemployees,provided thi teach
OUTS I OF FEES
improvements are not Intended oroffered forsale.If,howeveq thebullding or T
Impmvementissoldwithinoneycarofcompletlogtheowner-bullderwlll M1ave �aL.Tq
t)r�rden of proving that he did not build or improve for pu rp.ssof ask.). QTY. PLUn WFM ADD LONE APN
u I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7014,Business and Prcdesilons Code: I'FRIMI ANCE
The Contractor's License Taw don no apply to an owner d property who ALTER-DRAIN 4 VEM-WATER(FA)
wilds.r improves thmon, and who contracts fee such pyo"with a FEE SUMMARY
mp(laderW licensed pursuant to the Contractor's License Law. BACK FIAWPROTE�T.DEVICE
LII am exempt under Sec B 6 P C for this mason
DRAINS.flAOR ROOF,AREA,GOND. SANITARY Y_ N_
® Owner Date RECEB'f e
WOBm=t COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_
cert
❑1 hereby affirm that 7 have a ceaturan a of consent to op the rre,(S a RECEIPT s
3800,Lto ab
C.mpensatlon lrnunncexaartl(kd copy thereof(Sec. CAS EA.SYSTEM-1 INCA OUTLETS PARR FEE Y N
330Q Tab CJ
Il.liq N REC[PTX
C,, GAS E .SYSTEM-OVER
aBUILDING DIV
ISIONFES
ertlfed
copy b hereby famished. CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
Certified copy b filed With the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recci t# Sb
Rhbsectlon need nal b completed If the permit V[crone hundred dollars
(5'°°)ncefn ) WATER HEATER W/YpM/ELECT.R ENERGYFEE Y N
Irtify that uthe performance of the wmkfor which this permit bbsued,
I ahs 11 not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Worker:Compensation Laws of California. Date PAID -
0 Z Applicant NEW RESIDENTIAL PIMB. SQPY. Date Retmi t#
_Z 0 NVTICETOA]suLICt to If,
after rrs'Comaking Cois mpensation
krovisate of Exemption,of the
Lyou TOTAL:
shouldbecomesurtoto the comply
such pruatbn provisionstithe Lab or
~ N Code,youokM.Mhwhh comply wltM1 such proWions or this permit shall be
ILI — BUILDING FTE
W > deemed rtvokN.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihcrcbya/frm that them Ls a corutrualon lending agency for the perform ELECTRIC FEE
Z ancoof the Work for which this permit Is laved Sec.3097,Cls.Q TOTAL:
Q0 I<nder.Name b PLUMBING FEE
LL F tendce,Aaam„ QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
O W Imrtlfythatl have m.dthl.ppli tWnanastatethat The abovelnformatio^
ucorrect.I alimeto comply withal)etyand county ordinances and state laws PERMTTISSUANCE FEES PAI �'��C1p/
} N relatingtobdldingornslructlon,and hereby author.e representatives./this 2 60_t a
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. -
V _ (We)agree to save,Irdemd(y an d keep harmless the City d Cupertino ate Receipt#
against Ilablllties,judgments,macs and expenses which mayinanywayaxxae AIRFIANDUNGUNTT(TOI0,00(] M) SUBTOTAL'
against said city In.pnsaryence o!the granting of this permit.C AR AND NG UMT OVER IO,OWCFM) CONSTRUCTION TAX
Signatumof Appllont/C actor /D— � EXILAnusTIlODD6v/DUCT) CO SN TRUC ON TAX ID:
UA2AR OULSDIS LOSURE / b
Will the applicant or future building o¢vpants reorhandlehavrdou, HEATING UNIT CIO 100,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Fkvlth and SafetyCode Sedion 25532(a)7 HEATING UNIT(OVER 1W,"BTU) TOTAL:
M Yes M No fltz
Wlllthea llce.t or futumbuildin occv luxe ui ment ordevices VENTILATION FAN RESID)
PP 8 P+^ h P ISSIbANLSaF]ATE
which emit hamedow air contamivnb as de0ned by the Bay Arta Air
Quality Management District? BOB.ER-COMP pFE'OR 100,IXD ITV)
❑Yrs ❑"° EB 1 1991
(h ave read the Farar us No
requimrrcnta under Chapter 6.95 of BOILER-COMP(OVERIW,OW BN) F 4 1
the Glifer^ia Health A Safety Coda Sections 25505,25533 and 25534. 1 ,
undcrstard that ifthe bullding docs not cvmently have atenanL tM1at it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to not l/y the xcupa^t d the requirements which rust be met mile�y�
0 SSrIn' s
prior T°Lsauance da CcrtifiateyfwOmrpan
Ownerar au rlud agent 'Date LSSUEDBY\�l� v
TOTAL:
OFFICE COPY