21910 i APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— LL POINT PEN ONLY
Building Pored Identification PERMITNO.
Building Address:
21910
wnersName: one: A .
IU C-0#jV'j—. CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: ��.e� [Ac.No:
APPLICATION I PERMIT
N I— 3 .2 BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Amiatted/Engineer: Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DF.0 RATION
I hereby affirm that lam Bcenaed underprovlsi ns ofChapter9(mmmen APPLIANCES-RESIDENTIAL JOB DESCRIPHON
ingwlth Scctlon 7000)of DlvlGon3 o(the Buslneu d I'mfoulon.Cod,.nd my 1 1
license le In full force and affect. PANELS I'jZ;A ...t.
Llans Claes LION
Date Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 701-1000 AMPS
0Z Iundentand my plans shall be used sspubac records. OVER 1000 AMT'S A L E D $/`Q
O
Licensed Prafessiorui SIGNS ELIGTRIGL
6 -BUILDER DECLARATION M P U T E R
SPECIAL CIRCUIT/MISC
7 t.., Thereby affirmtOWNE exemptfrom the Contractor's License Law for the
'
Q following reason.(Section 7031.5,Business and Professions Code:Any city or
02 TEMP.METER OR POLE INST.
county which requlma Issuance,roruWuires th, aimprove,Ucam feesuch,orrcpatr ^• ^ �'
any structurepriortoits hat heiIssuance,aLorequlresthetto I hetfasuions of ltto
d POWER DEVICES W► it
Bk a e1gnM statement that M V licensed pursuant to the provisions of the -
3wG Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
SOS stun3ofnheBuainessend ProfeaHoru Code)orthat he k exempttherefromand VALUATION
O 5 the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLETSSWITCHESFIXTURES � v Q enol Q
applicant fora permit subjeatsthe applicant to a civil penalty effort more than
2- live hundreddollars rofthe500). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRICTION
7< ❑e as owner l the property,or my employees with ended as there door
som(So,.7 44,wBl doth.work and the Codure V not Intended or offered for
❑ sale(Sec.7014,Businessand Professloru Code:The Connractota License Law y
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RIS.UMTS
CC.• whodoeaeuchworkhlmeelforthrough hisown employed,provided that such
Improvements are not Intended oroffered formic.If,howevegthebeilding or TOTAL:
Improvement Issold withinoneyearofcomple lon,theownenbu0derwlll have
thrEl*rdenofpowmgthat hedid notbWld orlmprovetorpurposeotulc.), QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
I_I 4 as owner of the property,am exclusively contracting with licensed pp-EMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves thereon,and who contracts for such p(ojects with a —
r-A-der(s)Banned pursuant to the Contache.License Law. BACK RAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason I —
J-t�r3• Owner Data DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT p
V Iot--�i here affirm that I have a certificate of consent to self- FIICMIES PER TRAP SCHOOL TAX RECEIPT'N
�dif by Insure,(S a
rtiflate of Worken'ComperwHon lruurance ora ttdlford ropythereof l5ec. CAS EA.SYSTEM-1 IJCAOUTLETS
38M lab �a PARK FEE Y_ N_
Cc I N `" �Q 9 L V GAS EA,SYSTEM OVER 6(EA) RECEIPT N
Co ray BUILDING DIVISION FEES
rifled copy is hereby te city
Certified copy V(Teed withh(hthe city inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
ty
" CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ^ . L,
COMPENSATION INSURANCE �L KV
(Thlssectionneed norbecompleted lftheperat isforonehundred dollars SEWER-SANFIARY-STORM EA.200FT. Date Recei t#
(81I ormlew.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ll out than In thepersoniperformance n the waksfor
as to
co permit bound,othe —
I shall not employ any person In any manner n o to become subject to the WATER SYSTRM/TREATING
Workers mpewtlon laws of Ulllomla.Data Pplp
Z O NOTICE TO APPLICANT:If,akar making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
H W should become.ub)ed to the Workers'Compcocution provisions of the Labor TOTAL:
Code,you moat forthwith comply with such provisions or this permit shall be
C > deemed revoked. B L 1 FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihercbyafkrmthat there is a construction lendingagenry forthe perform ELECTRIC FEE
Z ance of the work for which this permit Is issued(Sec.3097,Clv.C.) TOTAL:
(� O lander'.Name I PLUMBING FEE
IL F Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iad By thatI have read thlsappliaHonand data that the above Information
uommet.I qme to comply with all etyand county ordinances and Gana laws PERMITISSUANCE FEES PAID:
} a relating to building mmHuctlon,and hereby authorize mpresMaHvese,fthEa
H 2 city to enter upon the above-mentioned property for lnapedlonpurposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an it keep harmieo the City of Cupertino Date Recel t#
V against llabllitles,Judgments,roGaend expense which maylnanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agarut said City N consquen of th satin of thle permit.
T ft a -12-11 AIR HANDLING NR OVER 10,000 CFM) CONSTRUCTION TAX
ignaturcof Applicant/C t r Data EXHAUST Hoop pv/DucT) CONSTRUCTION TAX PAID:
HAZARD MATERIALS DISCLOSURE
Will theappBant or into building ompant store or handle hazardous HEA77NC UMT(IO 100,000 BTU) Date RCCCi t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code t+��Section 75S37(a)7 HGTWG UNIT(OVER 100,000 BTLA TOTAL: D
Fj Yo u No
Will the applicant or iutumbullding occupant use equipment or device. VENTILATION FAN(SINGLE RERD) T ISSUANCE DATE
which eat hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DEEP OR 100,0(0 BTU)
�]Yee II��No
the bazer�
I have read materials rcyulrements underChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Coda Sections 75505,75533 and 75534. I ''II
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. f;1AR {� ".]?[
responsibility lbllity to notify nheoccupa ol the requircmenla which must be and
pnorto Issuance of a Ce flare --Parry
1. aawd t3
Owner or authorized t H Date ISSUED 81': �y
TOTAL:
OFFICE COPY