21820 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build g Address: n n 0
o// SC�nTe QL . cu . 9s�/4 a G j82
wnere
APPLlCAI1UNbUbM111ALUAih
CITY OF CUPERTIN4BUILDING DIVISION -
Contractor's Name ! SOW, Q c.No: APPLICATION / PERMIT
u Q nr a��- ?I BUILDING-ELECTMCA4PLUMRING-MECHAMCAL CATEGORY ' CONTRO .M
PArchitect/Engineer. - Lie.No: 'U b
•BUILDINGiPERMIT INFO'
QTY:"': fiCHCTRIC PERMIT .:r1FE6'
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyag,vithsectl 7000atl lmi.i ned under eBuMprovisions ofCsions ode and ne- APLIANCESRESIDENTIAL JOBB D.ESCRIIP`71710
Iicn..11.fon force of Dlvfect. (theguslnesaandPro(nslonsCrde,and my - O 1 4`VN/
license Is In full force and effect PANELS P
r r z
License Clams Clem 2
cote contra ctOr
ARCHITECTS DECLARATION 201-1000AMPS
qOX I understand my place shall he used as public mounds: OVERIODOAMPS SQ.FT.FLOOR.�A{�RFA $//SQ
.
Fr.
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
1`nry SPECIAL CIRCUIT/MISC --r
.Z p,"�, owing reason,
I am7031Z,exempt(romthe Contractor's License Law far t he ('`
O��Rfollowingreirequi open ttommineuand Propmonse=le hnytltyor ZOaoo
TEMP.METCRORIPOLE INST. (l Dt�O /" Q �TO
K4 "�� cwstycture requires.permRtoalsoreuirestheapmve,demolch,ormpairoutto
..1 any strictureprior lonahat he
alcensed ureanot to the t or rovisimof to POWER DEVICES
file a shed statement that he V licensed pursuant to the provislom of the -
3w� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3ofthe Business and Profession Code)orthat he V VALUATION
exempttherefromand .'
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any e3 UI'LET55WITCHES-FIXTURES . a .2, 13 0 6L C�
applicant for a permit subjectsthe applicantto a civil penalty of not morethan •J
�a
five, as ed owner ars of
NEW RESIDENTIAL ELECTR__SQ.FP, STORIES TYPECONSTRUCTION
�n ❑I,as owner of the property,or he employees with wages their sole
C compensation,will do the B.M...nal kand thes Code:There is et Contractor or License
d for
Law
$ q sale(See 7614,to ainowand Profesfprapeime who
builds orimproves
mp eves hemon Law
does doeot s
pplysuch torn imserofp rougherty his who nempoyees,p provided
that such and OCC.GROUP' RFS.UMTS
whowprovements amwork himsendedoroughedow aleph however,
thedilding or
improvements sold within
earofoompl tion,the oweveg deer ill have - TOTAL
improvement beold within mneyeam(completion,theowner-bullderwlll have
,lh rden of pmving that hedid notbundorlmproveforpurposeofsak.) (}Ty, ,::' .'.,�]!LUJ1'IBtHG-PE1tM1,T FEE;•+ F1.00DTANE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE Y]
contractor to cowtmct the project(Sec.7044,Business and Profeselons Code:
The Contractor's License law does not apply to an owner of property who
bu ALTER-DRAIN k VENT-WATER CA)lids or Improves thereon, and who contracts fee such ;,Wjects with a ® ..FEE SUMMARY:
cgp{racter(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE -
LI I am exempt under Sec. B k P C for this reaann
DRAINS FLOOR A,COND.ROOF,ARESANITARY Y N
OUTSIDE FEES
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION
by r CO FIXTURES PER TRA, SCHOOL TAX Y N
I Fere .farm that I have a l rt rate or consent to opytnmr a ars a RECEIPT X
certlfleAbC.) orkem'Compereatlonlmuranre oracertifled copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS 1� PARKFEE Y N
polis Lab CJ 1
Policy p BBCGAS EA.SYSTEM-OVER 4(EA) BINS PPT N
Com any BUILDING DIVISION FIGS
MCedifled copy is herebyfurnished.the
GREASE/INDUSTRLWASTE INTERCEPTOR PLANC14ECKFEE
MCem(ied copy,is filed with the city inspection division. f� �.�//�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRA PAID2�gT 6041-3
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(lOF('. Dale Recei t#
(This section need not be completed lithe permit V forone hundred dollarsa J
(S100)orleaa.) WATER HEATER V EL ENERGY FEE Y N
lrertify that In the performanceofthe work torwhlch this permit 1.1M -��j
I.hall not employ any person In any manner so as to become subject WATER SYSTEM/TREAITI 7= /— (( C3
Workers'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENT AL PLMB , Date Recei t# �L
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemptlo, o �. t s
should become subject to the Workers'Compensation provisions otthe abor� .TOTAL: 167q aZB
CC W Code,you moat forthwith comply with such provisions orthl.permit allbe BUILDING FE d
W > deemed revoked. f )L' -
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affir Chat there is a construction lending agency forthe pe ma, ELECTRIC FEE
Z once of the work(or which this permt is issued(Sec.3097,CIv.C.) TOTAL.
00 Lander.No. PLUMBING FEE' a
LL F Lender's Address QTY: :: ' MECIIANICAL,PERIN[T , '' FEE.:' MECHANICAL FEE OD -
U I rertifythat l have read this applicatlonand statethattheabove Information '1
O W Iscoreact.I agreeto comply with all city and county ordlnanres and state laws PERMITISSUANCE jM06 FEES PAID:
} 1 -
W relating tobuilding construction,and herebyauthorize representatives ofthb p
(. city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MFCH. Ia CC>. _
V ? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# .
against liabilities,lad ments,c d expenses which may In anyway accrue AIR HANDLING UNIT GO tO,ODO CFM) SUBTOTAL:
against said Ci i onee7u RRR'OtYhe- aafjng of thio permit
AIR HANDLING UNIT(OVER IO,OODCFM) CONSTRUCTION TAX
u �9^f� CONSTRUCTION TAX PAID:
Sigwmre�Appn Ali!A DOUSor Dnte EXHAUST HOOD(W/DUCT)
HAZA RDOUS MATERIALS DISCLOSURE
Willthe
as applicant or futurebuildingMu occupant store handle HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Season 25532(.)7 HEATING UNIT(OVER 100,0(t)BTU) a� TOTA
Y4s' No
Will the applicant or tore building occupant use equipment or d evices VENTILATION PAN(SINCLE RESID) ISSUANCE DATE 2.2l-7b
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Distria7 BOILER-COMP QHP OR 100,0W BTU)
4Yes ❑No
havc ria Healthe h
ardfrt Code,ls Sections
h5533 and
of BOILER-COMP(OVFR 100,D00 BTU) J�� 9.1,9Q1
the Caltloenlx Health building Safety Code,Semon.25565,ve a t and 25534.I tR
usponsi nd that it he tifytheocc pant not erently equize entsw which
that it mots my NEW RESIDENTIAL MECH. SQ.hT.
responsibility to notify the occupant of the requirements which must be met -
prior to issuance of a Certificate of Occupa ney. C4ly Of cup_"do
Date
Owner or authorized agent 'YI - V
ISSUED BY:
TOTAL; C�
OFFICE COPY.