21733 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification O / � J Q_T PEY.MITNO.
Building Address: V O ����,` W 21733
j'L/� i 36c � l oT 3�t
Phone: A A A
61?t=c. L�k% 61?otle CITY OF CUPERTINOBUILDING DIVISION
Contractor's N ame: / Uo NmAPPLICATION I PERMIT 1 �' R On
"� NTRBUILDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY COOLR
Architect/Engineer Lb.No:
/ .S.SF �fI Al L o NBUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Addnss PERMIT ISSUANCE I� 4 � K
LICENSED CONTRACTOR'S DECLARATION I�,�
with ton? hxtl amlbm3 ofthe usine3isbnaof Chapterodeandno- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Inense is tttlon 70m)ofd elect. fthc Buslnnsand ProfnsloneCode,and my
limn.le In NB force and diad. PANELS
Lt.Date class Lordr
Date Contractor
— UP TO 2DDAMPq
ARCHITECT'S DECLARATION 201-1000 AMPS
OZ Iunderstand my plam.haa be used u public records. OVERIOWAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
O
zFj Licensed Professional SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC 33 3
7 I herebyaflrnthat l am exempt from the Contractors License law for the
p folbwing reason.(Sectlon 7(315,Business and Professions Cade:Any dty or
FZt-.� IEMP.METEt ORIOLE!NST.
�Qa countywhich requiresa perrtdt to coruwct,alter,Imprwe,demnWh,orrepair
aS any structure prior to Its huuarcC also requires the applicant for such permit to POWER DEVICES
file a signed Gatermut that he Is licensed pursuant to the proWlom of the s
G13w Ii<i Contractor's License Law(Chapter 9(commencing with Section 7")of Divi-is G E C I VALUATION
E,LLo-f sion3.f the Buslc...rd Pr.lessl.mCodOmthat he exempt therefromand
Q -f the bash/or the alleged exemption. Any violation of Section]m L5 by any F S..,_
fhundred dollars(S -
Iu�o^ appllcantfora prrmitsubjMatheappllcant toe dull penalty ofnR mnrethan O TS t J U
I#i iveISM. ��,
1 as owner of the m orm 1 nwlth wa nae their wle '� S'IORIIS TYPECONMUCTION
p^�i ❑. P ork,a y emp.ye g
C7< com(Scc.7lon,wdldotMwork.andmeatocrum is le;TheaIntended oroffered Lar
5 p vie(Sec.apply
to an ow and f property
Code:The Contractors LI¢me law
does not apply toanownerofpropertywhobuilds or improves thertoryand OCC.CROUP RFS.UNITS
LL
who
provemuch am not mself orlhwgh hlsowne,11howemerAidMthabuch
ImprovemynbartnotImi.oneended arofco lot sale.thev e-bthebulldingve TOTAL:
Improvement isaold wlthlnoneyearofcampldbrytheowner-bu0derwBl have
t"nienofprovingthe he did nm WOd or empmve for purpose of sale). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am escluslvely contrading with 11¢nxd PERMIT ISSUANCE
contractors to construct the project(Sec.7011,Bushes ami Prof satimu Code:
The Contractor's License Taw does not apply to an owner m property who ALTER-DRAIN 4 VENT-WATER(EA)
Wilds or improves;thereon, and who contracts fear such pto)ects with a FEE SUMMARY
yf(+ctoKs)B¢nsed punuantrothe Contnd.rsll¢nae Law, BACK FTAWI'ROT[CT.DEVICE
E_,'am exempt under Sec. B 4 P C for this reason
DRAINS FLUOR,ROOF,AREA,GOND. - SANITARY Y_ N_
Owner Date - RECFIIT a
WORK MAN COMPENSATION DECLARATION MTIJRES-PER TRAP SCIiOOLTAX Y_ N_
❑I hereby affirm that I haw• l certificate of comfit to pythemof ora RELEIT'T N
¢nlficabc.) rkeri Compynsal.nlvunn<a ora adl(led copytherto(($ac. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3EW,LbCJ
Com ny flush AU ,-t. GAS EA.SYSTEM-OVER 4(EA) BUILDING VI SIONFE ES
[BCemfirdmpy is heed with the
city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
r1Cemlie l copy is tied with tis city W pMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASETRAL' PAID
COMPENSATION INSURANCE SEVEt-SANITARY-STORM EA 310!,'1' Date Remi tp
(This section need not be<omplded Bthe permit isfor one hundrM dollen
nO)«
1lyra.)
WAIEy� ERW/VENT/E.ECTR ENERGYFEE Y N
certify that tithe pedornon¢of the work(orwhlch this permitla saved,
I shall not employ any person In any manner eo ss to become.ubpot to the WATER SYSTEM/TREATING
Worken'Compynsatlon Laws of California. Date PAID -
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FI. Date Recei tl1
Z O NOTICE TO APPLICANT.If,after ma king this Certificate.(Exemption,you
Fshould becomesubject to the Workers'Compamatlon provisions of the Labor TOTAL:
W Code,you most forthwith comply with such provisions mthis permit shall be O,So
Wj deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGI CY SEISMIC FEE i o
a Z I hereby affirm that then Is a construction lending agency f.rthe perform- ELECTRIC FEE
Z a.or fine work for which this permit is issued(Sec.3097,Civ.C.) TOTAL'
(,) O Lendrr'.Nane�Y/�. PLUMBINGFEEp,
LL Lc.dcr.Addnsa (yrY. MECHANICAL PERMIT FEE MECHANICAL FEE �jS
OW I¢rilfythatl love read(hiss Ilatbn and GaethattheaWwInformatlon
S is corn(l agree to comply with all dty and county ordinances and Gate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
I" Z
city to enter upon the above,mentioned property for Inspection purpose.. ALTERORADD]OMECH.
(We)agree to save,Indymmfy an d keep harmless the City of Cupertino ate Reteip
V against liabilities,jndgrrxm,cxnt...d c.,rueawhlch troy lnanywaya.c AIR HANDLING UNIT(170 10,1100CFM) SUBTOTAL:
agalrot sa1dLC'ty1.c.n.equence the granung.nhla permit. AIR HANDLING UCONSTRUCTION TAX
Q _ y _G MT(OVER lO, p CI
fX >L) f^ 8'
7
Signature.!Appll fit/Contractor Date IXEIAl15'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA RDOUS MATERIA DISCLOSURE
Will the applicantdefined
b or future building antode, hhand9.h,and
HEATING UNIT 00 100,010BN) IJate Recei tk
Heaftulasdeflnydbyt SCupemno MuNdpal Code,Chapter 9.1;and the �--
Flralthand Safety Cadr Sydlon 2553](x)7 HEATING Uh77(OVER 1OO,IXID B7'U) TOTAL:/>VS— jf
❑Yo ri No �,��-3
Will the applla..air ont.milding occupant use theequipmentAre.devices VENTILATION PAN(SINGLE RESID) ISS Nl'.L'IUATE
which ymit la erdoua air contaminants as dented by the Bay Ara Air
Qaaluy Maragemunt District7 BOILER-COMP p]-3'OR 100,000 BTU) FEB 141991
�?n he 9No
"(h read Health
cam materials
ocie, ectionlr25505, 5533undand 255 .1 of BOILER-COMP(OVER 1fq,OW BN)
the
erstan t Health 4Safety Code,not cure 5505,25577 and25531.I �aT1�,
understand that iRhfy the leg doespart of the currently hich,thatb met NEW RESIDENTIAL MECH. �.FT V'- A..ne- '-s
rapomiblllty to edify the part of the requirements which must be met
prior to issuance of a Certificate.!Occvoan
Ownerm..th ;gem `+ Date ISSUED BY,�
TOTAL:
OFFICE COPY