21930 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.— USE BALL POINT PEN ONLY
Building Project ldendflcatlon- PERMIT NO.
Building Address: 21930
Zo30o S-IEJLaS uc,cs(c 8L-J.D. v3
�) one: A A A
PROM67HL° D✓�V• CITY OF CUPERTINOrBUILDING DIVISION �j /
Contractor's Name: - Lie.No: APPLICATION I PERMIT 3— (q
_ L
CALMCALMN 3 1 SITS' BUILDING-ELECTRICALPLUMBING-MEfCHAMCAL CATEGORY COp1TR(JJeg�Z
Architect/Engineer: ,Lic.No: - ��I /•�
- -( QTY'.: ,ELECTRIC PERINTF ",EPEE BUILDING PERMIT INFO`
Address:/0I M! �D OR. S]E.110 SA VOLS PERbIITISSUANCE •(!� ❑ ❑ ❑
LICENSED CONTRA OR'S DECLARATION
I hereby effimthat I am liceneed under provisions of Chapter 9(comment. APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
Ingwlth Sectlon 7000)ofDfvikm3 o(the Businesssad ProfeseiarsOcce,and my -r-����
Brenre le In furs r ana effect. 3 95775 PA'vQs
License.iris effect'
Date Contractor
ARCHITECTS DECLARATION 201-IOW AMPS
9
0 ZO I understand my plane shall be used as public records. OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ.FT.
RUB Licensed Pmfemioml SIGNS ELECTRICAL
! 6 OWNER-BUILDER DECLARATION SPECIALCI2CUIT/MLSC
F, mvingra(@mthatla 7MI.5,exempt from the Contractor's Licence Lw fort he
2 O^5 following reason.(SeR1on 7Qit.5,Business and Professions Code:Any city or
I hereby TEMP.METER OR POLE INST.
� countywhich requires.pemdttocow[mcq ffiep Improve,demollsh,or repair
g� .'e.: anyelruceum prlorto its issuance,alsorequirestheappllcent forsuch permit to POWER DEVICES
L5 9 a file a signed statement that he is licensed pursuant to the provisions of the <
w Contractor'sL(ceree Law(Chapter9(commencing with Section 7000)of Divi- VALUATIONo�
t`n SWIMMING POOL ELECTRIC
sion3o(the Busineesand ProfessloruCode)orthat hely exempttherefmmand aq-.
Othe balls for the alleged exemption.'Any violation of Section 7031.5 by any OUTLE7SSW[TCHESFIJCM4ES ;,, /' D
rsappliant fora permit subjects the applicant to a civil penalty of not mans thanVo five hundred da16n($500). NEW RESIDENTIAL ELECTRI,as owner of the property,or my employees with wages as Iheir sok RI TYPE CONSTRUCTION
mpensatlon,willdothe work and thestructure is not intended or offered for
O sale(Sec.7014,Business and Professions Code:The Contractors Wanes Law � .
2 does not apply to an owner of property who builds or improves thereon,and
who does suchwark hlmeB orthrough his own employees,provided that such . RO RES.UNITS
1rGprovements are not intended orofferedforsale.If,hewever,thebuildingor improvementissoldwithinoneyearofcompletion,lheowner-bu0derwBlhave
th rdcaof proving that fie did rat build or improve for purpose ofsale). •QTYPi �C[7MBING"PERM . .!
FLOODIONE APN
I,os owner of the property,em exclusively contracting with licensed PERMIT ISSUANCE
17he Roraoconatmnsect law duect( ec.net apply
Business and of propertrofessionsy
Code: I Z,QQ
The Contractor's,orimpo Lice.the Law does oar apply tct an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds,or improves thereon, and who contracts for seL p.okcb with a
m,,IlIltjjacar(e)licensed pursuant to the Contractor's.lanae Law.' BACK FLOW PROTECT.DEVICE " 'r' 'FEE SUMMARY".
LJ I am exempt under Sec. 0&P C for this reason
trwner
DRAINS FLOOR A,COND.ROOF,ARESANITARY Y N
Date RECEIPT If
WORKMAN COMPENSATION DECLARATION SCIdOOL — N_
ml hereby affirm that I have a artiRute of consent to eel(-insure,ora I FIXTURES PER TRAP a'a TAX YRECEIPT a
certlflateo(Worken'Compevatlonlmurana orattrtllled copythereo((Sec. GAS F.A.SYSTEM-1 INCA PARK FEE Y N
F 3
ouga PSO 43(0935"_ DING 7'x
GAS EA.SYSTEM-OVER 4
. Cam anv A} (EA) BUILDING DIVISION FEES
Certified copy is filed
the city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division. 1��O
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA5ETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM PA.2WFT. Date Re t#
Qhwless.) need na Mcompleted OlM permit V(Drone hundred dollars
($1 I wrifess3 WATERHEATERW/VENT/ELECTR ENERGYFI Ss Y
' Ittrtlfy that In the performance o(the work(orwhlch this permit is Issued, \—I\ —
• I shall not employ any person In any manner so as to become subject to the WATERSYSTE
Workers'Compensation Laays of California. Data M/TRFATING PAID '
0Z Applicant NEWRESIDENITALPLMB. SQ,FT. ecei t#
Z NOTICE TO APPLICANT:](,after making t his Certificate of Exemption,you
{" should bemms subject to the Workers'Compensation previsions ofthe Labor T TALI:
W
Code,
you
=at
`forthwith comply with such provisions or this permit shall be
J BUILDING
s oO
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Iherebyq(firtnthat there Is a construction len ding agency the perform TOTAL: ELECTRIC FEE
sada of the work!or which this permit is baued(Sec.3097,Civ.C.) � .�
02 Landers Name PLUMBING FEE
LL I- Lender'.Addrese QTY,` ' MECIiANICAL.PERMIT' •`'-FE$;i`' MECHANICAL FEE
OW 1camly thatl have read thisapplimthmand statethatheabove Information
C Incurred.lagrectocomplywithallcityand munlyordinances and slate laws PERMITISSUANCE FEES PAID:
>. relating to building mmtmctlon,end hereby authotlze representatives ofthis
H 2 city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei It
— (We)agree to ave,indemnify an d keep harmless the City of Cupertino
against liabilities,judgments,mrtsand expenses which may In any wayamue AIR HANDLING UNIT(T010,000 CFM) SUBTOTA
against said City in consequence of the granting of this permit.
AIR HANOUNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appfiant/Contractor, Date EXHAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID: '
HAM R DODS MATERIALS DISCLOSURE .
Will the applicant or future,building occupant store or hand Is hazardous HEATING UNIT(TO 100,000 BTU) Date RCeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Ion 25532(.)? HEATING UNIT(OVER I00,000 BTI) TOTAL'
r7 Yea 16No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management Dist ? BOILER-COMP(311P OR 100,000 OTU) PAM
4 Yes No
have read the baza ouamatcdalsrequirements under Cha er 6.95 of BOILER-COMP(OVER100,000 BTU) p Q N�yQ♦`
r the California Health&Safety Code,Seetloow,75505,25533 and 25534.I APR S
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Fr
responsibility to notifythe icteof oftherequirements which must be met �'�Y`'"au•eR
prior ns Issuance of a Certificate of Omhe requirements
C
Owner or authorized agent Date ISSUEDOY: %IJIN.AVfU�C.
TOTAL:
'OFFICE COPY