21590 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proteel Identification 7 PERMIT NO.
BuBding Addrea: ` P—twolew � - 21590
weer, me: LI �A, , one: -�� A A
WIfI 6feP CITY OF CUPERTINO-BUILDINGDIVISION q
• contr cetnr,Name:{{ t� Lie.No: APPLICATION I PERMIT
L }'lQL{NlP ? 4I BUILDINGS-EC7RICALI'LUMBINGMFOFIAMCAL CATEGORY CON7ROCy/7
A / gineer. el Llc.No: 1L9 s7
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: ,I;-Or w PERMITISSUANCE '�� �/ ❑
LICENSED CONTRACTOR'S DECLARATION I�J
I hereby affirm that l am licensed under provisions of Chapter 9(eommmc APPLIANCES-RESIDENTIAL JOB DFSCRIPTION
l.gwth Sen film7000)ofDivtlWo 3roo��fthhallusinessand ProfoslonsCode,and my PANELS
nae Cls Lie.N l
Date I�T Cnmractnr ice!T+T-SRxL
ARCHITECT'S DECLARATION 2M-1000AMP5
q0't I understand my plans,halbeused a public records. OVERIWOAMPS SQ.Ff.FLOOR AREA S/SQ.FL
rO.
L+�Fi Licensed Professional SIGNS ELECTRICAL
<�a� OWNER-BUILDER DECLARATION SPFOIALCIRCUIT/MISC
t.., = I hembyafRrm that I.exempt from the Contractor's License law for the
7.O M following reason.(Semon 7�t5,Bualnen and Pmfnabv Code:Any dty ar
TEMP.METER OR POLE(NST. ts�
q�p mvntywhlch rcqu4maperMttomnstruct,allrr,impmve,demolish,orrepalr
3 anystruc mpdortoiU suancgal rcNulrestheapplimntforsuchpermitto ppWFR DEVICES
EE 0.U file a signed eatemcnt that he Is licensed pursuant to the provisions of the
Contractor',License Law(Cha er9(commencin with N (commencing SWIMMING POOL ELECTRIC 30 slon3of the Business and ProtectionsCode)orthat hebexempt thercfromand / VALUATION
a' S the basis for the alleged exemption. Any violation of Section 7031.5 by any
Q� OUTLETSSWITCtIESFIXTURES Q
appllcantfora permitsubjecLstheapp8cant to civil penalty dna morethan � C I I � �"' 00
1pppS five hundred dollars($500). NEW RESIDENTIAL ELECTR
9.d E]1,as owner of the property,or my employees with wages a their sole �'�' STOWES TYPECONSTRUCTION
compensation,will do the work and the structure la net Intended or offered for
5 O sale(Sec.70,1t Business and Professions Code:The Contractors License law
�$$ does em.pply toan owner d property who Wilda or Improves thereon and OCC.CROUP RFS.UNITS
whodoessuchworkhtmself orthrwgh hisown employees,provided thatsuch
Improvements am not Intended oroffered for sale.If,however,lhebuliding or TOTAL' Iliac:
impmvementL wldwlthinoneyearofmmplettogtheowner-buRderwillhave
It[,
yLdenof provingthat he did not build or Improve forpurposeofale.). QTY. PLUMBING PERMIT FEE FDO ZONE APN
J 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATSt(E/q
Wilds or Improves thereon,and who contracts for such paojeca with a
oht(actm(s)Reenact Pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec. B b P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLA RA TION FIXTUMFS PER TRAP SCI TOOL TAX Y N
Ell hereby affirm that 1 have a certificate of consent to seI-Insure,or RECFjPp N
certificate ofWorken Compersatlonlrenomoce ora certified copythemot(Sm. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.)
Policy N RECEIPT N
Com any GAS EA.SYSTEM-OVER N(FA) BUILDING DIVISION FT.ES
ffCedlfied copy Is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
rlifled copy Is filed with the city Inspection division. �y q
_ CERTIFICATE:OF O(EMPTION FROM WORKERS' GREASE TRAP PAID Q
COMPENSATION INSURANCE SEWER-SANITARY-SNRM EA.200FT. Date RCCCI t# §b,?8
(This auction need not W completed lithe permit is forone hundred dollars
(Slw)orlesa.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y_ N_
I mm ythat N the performance of the work torwhIch this permit Is issued,
I shall not employ any person In any runner an as to become subject to the WATER SYSrpM/TREATING PAID 1"L\'1-CCo ;'QSLq
Workero Compensation Laws of California. Date
OZ Applicant NEW RESIDENTIAL PLMO. SQFT. Date liecei t
Z O NOTICE TO APPLICANT:It,after making this Certificate of Exemption,
HW should become subject to the Workera Compensation provision,of the Labor TOTAL:
� ; Code,you mustfodhwlthcomply Mthwu pmvblamorthleper tahallW BUILDING EE t
deemed nevokud.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE �s
4 Thereby orkfoffirm which
bacomitb,Issu lendingagency W7,Cil.C.) perform TOTAL: ELECTRIC FEE a
L) Z Leader the work for which this permithissued(Sec.3097,Civ.C.) PLUMBING FEE
LLQ Lenders Name aN��N—
LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ♦W
U I certilythatl have read thisappBratlon and date thattheabove Information
O W is correct l agree to comply with all cityand musty o dnanmand date laws I PERMIT ISSUANCE �.� FEES PAID:
} C relating to building construction,and hereby authorize representatives ofthis
Z cit to entero the aWvcmentioned propertyfor W ion ALTER ORADDTO MECH. Date Receipt#
~ N city
agree upon
save,Indemnify an d eehatdess the ity purposes.
nlw
V against liabilities,judgments,costsand expenses which may In anyway accrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
I..�a 1 � �I AIRHANDSNG 11NIT(OVEt I0,000CI\1) CONSTRUCTION TAX
i Sig ature of Appliont//IC.�ntootor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheappBa at or future,building occupant store or ha ad le haaardous HEATING UNIT(TO I OO,ODO BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
I lealth and Safety Codr Section 2S532(a)? HEATING UNIT(OVER IOQOW BTU) TOTAL:
MY. , N No
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISWQNCFy DATE
which emit hazardous air contaminants a,defined by the Bay Area Air 6A��ap7
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4 Ya he 9 No
have read ealth&Sfet mode,ls mqu Sections
ectionmementsi 05,25533 and apter 25534.1 of BOILER-COMP(OVER100,000870) JAM N7'�Q I
theerstand that if the
building Cods not
m25505,vea tenant,that
1 1-y4Yl 9 u'KC
understandthatthe
does note�rmatly which that b Lamy NEW RI3IDCN77AI.MECIi. SQ.IT.
responsibility to issuance
ce notify the occupant of the rcquircmenta which must W met ��
prior to Issuance of a Certificate of Ocmpanry.
Owner or authorized agent Date ISSUED
TOTAL: a
OFFICE COPY