21502 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
Building Address: s�i�r.� ���,,� . . _ 21502
sonarsName; - one: p
�FU L—V N l O 96- �/ CITY OF CUPERTINO-BUILDING DMSJON ^'ID
ContractotaName: Lie.No: APPLICATION / PERMIT — 7
�(�FA'I'II'F1G /YC?sI-)cIILS' rC9'\�.Z4 BUILDING-ELECTRICALPLUMBING-MECFIAMCAL CAT ECRY CONTROLM •
AYchItM/Englruer. Lie.No:
tiQTY ELECTRICPERMIT FEE BUILDINO.PERMIT INFO
Address: 6 PE MIT1SMUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S `ECLARATION
thereby
sfftr thatlamlicenxdunderpm Wonsof Chapter9(rommenc APPLIANCESRESIDENIIAL JOB DFSCRIP770N
Ingwlth Salion7000)of DiWslon3ofthe Buslneuand ProfetaonaCode,and my
Iicenselslnful a andel(eet. PANELS
License Clam LIC.N d
Date - - Contractor I l+�/Fr 4_ l._-�
ARCHITECTS DECLARATION 201"1000 AMPS
�7 I understand my plans shall be used as public records. OVERIODOAMPS N SQ.FT.FLOOR AREA S/SQ.FT.•
p O
E Licensed Perfesalorul SIGNS ELECTRICAL
GG 6 OWNER-BUILDER DECLARATION
Z
jn ,b SPECIAL CIRCUIT/MISC'
7 p., thereby affirm that lamexempt fromthe Contractor's License law for the
oo following...(Se Hon 70315,Businen and Professions Code:Any dty or
CZl'o9 cvuntywhich requiresa perootwearutrua,alter,Improve,demolish,oreepair TEMP.METER OR TOLE[NST.
g`� 3 ,nystm=mpdortolt,Issuance,alsomquirestheapplicantforsuchpermitto
61 file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3w
Contractor's License Law(Chapter 9(commencing with Section 700 D)of Olvl- �" a
OIMMING POOL ELECTRIC
ron3 o(lhe Bminnaand Prv(emloru Code)orlhat he la exempt therefromand SWIMMING
- VALUATION the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSeWITC m FS
�4 appllant for a permitsublect.theappBcant too civil penalty of.et more than 1'-
five 1,as
owndeler
of the pr). NEW RpgpENTT I.pyF,CTRT_y�,pp STORIES TYPE CONSTRUCTION
e as owner of the properly,or my employees with wages thele sole
C ¢ "compensation,will d o the B..uncss,and rf the
omCdurela notintended or License
d for
Law -
'S O sok(Sec 7614,Bue4iesa and Prolevloru Code;The Centractofe Llcerue law
f7j $ don not apply to an owner of property who builds or improves thereoq ap'd x.,',l OCC,GROUT' RFS.UNTFS.
who docs such work himself orthrough his own employees,provided that ash
Improvereenmam not Intended oroffered forsale.If,however,thebuilding Qr �) r4'�y . TOTAL:
improvement b sold within one yearofcompletiom the owner-bullderwill ha
tlurden olpmving that he did Not build or improve for purpose efsakJ. TY. PLUh181 GPE MIT FEE FLOOD 7DNIi APN
u S as owner of the properly,am exclusively contracting with licensed IT- PNCE
contractors to construct the period(See.7044,Businea and Professions Code:
The Contractor's License Law does net apply to an owner of property who I ALTER-D k VENT-WATER QiAj
Wilds or lmprova thereon,and who contracts for such p(ofeds with a -
c tt[ador(s)Bcenwdpunuanttothe Contmdor's Lkenx Law. FEE SUMMARY
BACK FLOW PROTECT.DINICE >[^
IJ I am exempt under Sea B k P C for this re.
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMANCOMPENSATIONDECLARATION psPER TRAP SCHOOLTAX Y N
pl hereby afftm that 1 have a cerHfiate of consent to self-Insure,or a RECEIPT
M
certtfl iteofWorken'Comperuationlmumnmoracedifk copythereo(lSec.
3800,Lab CJ GAS FA.SYSTEhf-I INCA UTLLTS PARK FEE Y N
Policy p GAS PA.SYSTEM ER 4(W RECEIPT p
Co any B UI L DING DI VI SION FEES
IY1Certified copy to hereby furnished. ASTE INTERCEPTOR PLANCHECK FEE
fL�J Certified copy b flied with the city ty Inspection division. GREASE/INDU
CERTIFICATE OF a ETMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER-SANITARY-STORM EA 200FT Date Revel t#
CTMssedion need nil becompleted lithe permit V foroou hundred dollars D
($1I aperformanceem3 WATER HEATER W/VENT/FLECTR ENERGYFEE Y N
]cedllythat in the performanceof the work for which this permit is kaued, '
I shall not employ any person in any manner w as to become subject to the WATER SYSTRIVIMPATING
Workms'Compen.aHonlawa of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQFT. Date Revel t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become.object to the Workers Compensation provisions of the Labor TOTAL:
F N Code,you must forthwith comply withsuch provisions orthit permit shall be BUILDING FEE
j decreed revoked.
d C CONSTRUCTION LENDING AGENCY SEISMIC fTE
I herebyalflrmthat thereh e construction lending agency for the perform- ELECTRIC FEE
Z ance of the worRfor which thbpermltk Tssued(Sec.3097,CIv.C3 TOTAL:
Q O Lender.N.
PLUMBING FEE
LL F IRnder.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE V
OW Icenify Natl have read thisappllationa to that Il,,=ve In formation
1 bcormd.Lgreeto comply with allety." un ordlnanceeand.talelawa PERMIT ISSUANCE .(� PEES PAID:
} W relating tobulidingmmtrudloil,andhereyouth rlurepeesentativesoithei
(- Z city toenterupon the above-meet ne)p perty(rinepectlon purposes. ALTERORADDTOMECH. Date Rceei f#
V - (We)agree to ave, demni an ep har em the City of Cupedlna P
agabutllab' ksjud nt' son a pensea hlch ma aeyway..o AIR HANDLING UNIT(TO 10,000 CIM) SUBTOTAL'
.gal a sty In c sequen oft antin of this pe t.
\/ h AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
SI ! pp rant/Contra or to E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO RE
Will the applicant or tutors building occupant smrc or M1a h rdous HEATING UNIT(TO 100,000 BTV)
material as dented by the Cupertino Municipal Code,Chapter 9. andthe Date Rotel f#
Health and SafetyCode Section 25532(a)i HEATING UNIT(OVER 1001003 BTU) ,(f� TOTAL: OD
F1Yes No
Will the a ppliant Men building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS9,FA,� ATE
which emit hazardous air contaminants as defined by the Bay Area Air
.� Qua llty Management Distdd7 BOIF.R.COMP OI-R'OR 100.000 BTU)
I .ca , 1-I No NOV 3 l
hos-rei.Il eth&SafutyC er,SLdiqulremenbunderChaple4. I of BOILER-COMP(OVER 100,000BN)
01
the Gltand to at If t M1 k Safety Cade,Sdiore 25565,ntly have
a tenant,and 25534. I
und.ratanity to if tifyhe uilding the.ccupocs of t erre.incenveahickthatb met NEW RESIDENTIAL MECH. SQ.FT.
rnpoto Issuance
notify Leri este of ofthercqulrcmenls which must be met IaGu otcoseea ft
pride to Issuance ofd Cerllfiate of Ocnapanry. wV Yoawuw
Owner or authorlud agent Data TOTAL: (]O ISSUEDBY: �
OFFICE COPY