21912 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prr°Feat 11dmtlflntlan ,( / Pr WTNO.
Building�DsAddress:
�a 21912
mere one: q
�. JL CI OFCUPERTINO-B ING DIVISION ^_�^`•�
c.nta •.Name: LIc.Ne: APPLICATION / PERMIT
�V.V! BMLOINGELEC]RICALMUMBINGMECHANICAL CATEGORY CONTRCC
A ItH�nm ¢rtijl�yfs a-9i4 °
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreas:2g- /Q/a�1 /� SG/ 1.V
PERh9TIS5UANCE b ❑ ❑
LICENSED CONTRACTOR'Sla LARATION
I hereby affirmthat lam licensed under provWomof Chapter9(mmmenc APPLIANCFSRESIDENTIAL JOB DESCRB'HON
ingwlth Sedion7ODO)of Dlvkston3oflhe Buslnemand Professions Code,and my PANFlS �+ Q'1G.-�I"
license la lnfu .r�y yf N ��
License Class '�Ic.
Date /i Contractor _ a_� /I1/C 12QFFZ'�'
—7 ARCHITECTS DECLARATION 201.1AMPS
a0�Z I understand my plans.hall be used as public records. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
.4zu ° Et D
C U U Licensed Professional SIGNS ELECTRICAL
<Q Y1
OWNER-BUILDER DECLARATION ��
I hereby afBnn that I OWNE -BUIL ER DE Contractor's License law(or the SPECIALCLYCUIT/MLSC
7 a following reuon.(Samon70f1.5,Businessand Professions Code:Anycityor TEMP.METER OR POLE INST. N4 P
a l"� c°untywhlch relulresa permit tomrelmR,alter,Improve,dennlish,or repair19
a' �..1 anyaructure prlortolb issuance,ebomqulresfheappllrant(°r such pertNno
POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
31°.,� Contractor's License Law(Chapter9(commencing with Section 7(1(10)of Divi- SWIMMING POOL ELECTRIC VALUATION
F,uO ato.3of the Business and Profsaske.code)orthm he is exempt therefromand
S° tW bash far the alleged exemption. Any violation of Section 7031.5 by any ^
g^
POP 77 OUTLETSSWITCHESFlXTURESZZLE 'Z'L�� 0 00
Q applicant permit applicant civil pculty of not more than
�Y five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
L as owner of the property,or my employees with wages a their sole
� 6
compensation,will dothe work and thestructure brof Intended or offered for
go .1.(Sec.7044,B.Arsou and Pmf.kms Code:The Contractors Lhx ue Law
does not apply to an owner of property who Wilds or trepmves thereon,and OCC.GROUIa RIS.[INKS
who docssuchworkhmeartf orehroagh hisownemployces,provided thatsuch qO
improvements are not intended orof(ered for sale.If,however,thebuilding or TOTAL: l['(T
improvement issold within oncyearofcompletlon,the owner-W Ilderwlll have
thfumen of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ a owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contracc t ors to constroct the punter(See.7044,Business and Professlou Code: UQ
The Contneorb License Taw does net apply to an owner d property who ALTER-DRAIN&VEN-WATER(EA)Wilda or Improves thereon, .rad who contract. for such project.with a FEE SUMMARY
cell+ct.of licensed Pursuant to the Contracts'.License Law. BACK FLOW PROTECT.DEVICE
(_I I am exempt under Sec. 0 k P C for this rcasnn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT'N
WOR KMAN COMPENSATION DECLARATION FIX'IVItFS PER TRAP O/1 SCHOOL TAX Y N
n�hereby affirm that I have a certificate of consent to self-I.au s,or VV RECEIPT N
bo(Worken'Compensalloninsurance ora certified copy ehermf(Sce. GAS FA.SYSTEM-1INCA OUTLETS PARK FEE Y N
Policy
Tab C3 —
Pollq p DING DI'N
Co�mparay GAS EA.SYSTTM-OVER d(EA) BUILDING DI V ISION FEES
I Iccitified copy is hereby furnished. PLANCHECK FEE
ertified mpy�b filed with the city inspection division GREASE/INDUSTRL WASTE INTERCEPTOR ^�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER.SANTTARY-STORM EA.200F1'. Dale Recei t# l
(This section need nut lot completed B the permlt isforone hundred dollars
(St00)or less.) WATER HEATER W/VENT/ELFJCTR ENERGYFEE Y_ N_
I notify that In the performance of work for which this permit Is Issued,
I shall not employ any person In any manner m as to become subject to the WATER SYMIM/TREATING
WorkersCompensation Laws of California.Date PA
OZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z NOTICE TO APPLICANT:If,a her making this Certificate of Exemption,you
O should become subject the Workers'Compensation provislons ofthe Labor TOTALL
P:
N Cods,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE 11
dmed revoked.
III > mCONSTRUCTION LENDING AGENCY SEISMIC FEE , q q
LLQ Iherebyaffirmthm there is a construction lendingagenry,forthe perform- TOTAL: Q- J ELECTRIC FEE J„�_V
Z anon of the work far which this per ued(Sec.3097,CIv.CJ
O O lander.Name PLUMBING PEE 30. ND
LL F Lc.dtr.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 4 B:
U Imdlfythailhavemadthsap Icatlonandstatethattheabovelnformtion
Ow Iscoreco.l.greeto complywith all etyand county ordinance and state laws PERMIT ISSUANCE z.uD FEES PAID:
} (L relating to building construction,and hereby authorize representatives ofthrs
U) It t enter. ntff
d forW I ALITR ORADD TOMECH. SOD
F Z c y ° Wp•°per7 p °"purposns. Date Receipt#
(We)
agree t d keep horn the City ofCupertino
agWtllaW e.penuawhLeh ma ylnanywayaccrue AIRPIANDLINGUNU(TO10,000CFM) SUBTOTAL:
agatee granting dthls permit.
A act HANDLING uN1T'rovER lo,aao cFM) CONSTRUCTION TAX
Si
tore cam/ ..trader �i ate - EXHAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA DOLS MATERIALS DISCLOSURE
Willtheapplica f w.bulldingocmpantatorcorhandlehazardou HEATING UNIT(TO 100,000 BTU) Date Recei t#
retial as de(Ine the Cupertino Municipal Coda Chapter 9.1 7,and the
Ic lhand Srf osi ff-lon25532(a)t HEATING UNIT(OVFR 100,000 BTU) TOTAL:
Ye, No
Will the appli.etorfuture building occupant use equipment or device, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazard...air e.etaMmnts a.defined by the Bay Area Air
Quality Management Dlstdct7 BOILER-COMP OHP OR 100,000 BTU) 3_QO PAD
AYye. n❑No A�i1
, read the hazardous materials requirements u rider Cha peer 6.95 of BOILER-COMP(OVER100,000 BTL)
the Cellfornla Healthk de, 1ou25505,25573 and 25534.1 /,I�R 1 7 ' Q,
understand that 11th Tiding en currently have atenanL that lt4my NEW RESIDLNTIAL MEGI. SQ.FL 11-(5 3 C
responsibility to a requirements which most be mer
prior to ni cm a
Cl -7rb�RR
Ownero Be. � to ToTOTAL: O)A`U iSSUEDBY: v` LAUI
OFFICE COPY