21435 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES`— USE BALL POINT PEN ONLY
Building Project Identification t .e PERMIT NO.
Build ing'Address: , .. .. 21435 •1
S:
nera seer. _ APPUCA110N SUBMIll AL DATE
CITY OF CUPERTINOBUILDINGDIVISION p C
Contract 'a ame:' - Lie.No:- APPLICATION / PERMIT
./ — ( `
S .BUfLDINGELECTRICAL.PLUMBINGMECHAMCAL CAT)GORY CONTROL x
Architect/Engineer. - Lk:No: -
IQT'Y{t`i �t i1, 4ELECTRICPERMIT Io ,' 1i FEBttt' ' ��F''ti 1BUILDINGP.ERMl1''INFO,w',-. ,1 � '
S. 9, X97-3 p PFRMITISSUANCE o
LICENSED CONTRACFOR'S DEC R I1gN-/��j�
Iherebyaffirm that l am licensed under provisionso h`x'ptfr 9(c�mmene- APPWANCFSREBIDENTIAL JOB DESCRIPTION .,
ir�gwlth SecHon7000)of DivIsioe3ofthe Busloessand ProfessionsCode,and my`
license Klass jo�ga9d e.N PANES
Of Date Chas (C J6Wc.x
Date
gem, r�!2= — _ , UP TO 200ANMS
PS
ARCHITECTS DECLARATION 201-R300 AM
of I understand myphreshallbe used as pubberecreds.. OVER 1000 AMT'S SQ.Fr.FLOOR AR� 5/SQ.IT.
��qquuO AL
� Licensed Professional SIGNS ELECTRIC
� � - ,
F<6 OWNER-BUILDER DECLARATION
o j, Ihsrebyalflrenthal l am exempt from the Contractor's License lawforthe SPECIAL CIRCUIT/MISC
2Z following mason. Professions Code: my or -
F f:Epp TEMP.METER ORIOLE INST.
countywhkh regrtoiaperamt a omquialter,Improvntfoolch pe repair
qqq'''•�•� any sts,inedst. ervot Wt he
llmeascl 'na"n"'thoproul'chpertNtto POWER DEVICES
r4 � ,file a signed&atemcnt that W Is Ikemed pursuant to the proWelons ot,thc _ - r
Ow Contractors License Law(Chapter 9(mmmmcIrgwithSrmIon7000)ofDIVI-
:0 cion 3 ofthe Bukressand Prmfesslmu Code)orthat hels exempt therefromand SWIMMING POOL ELECTRIC 71— VALllAT10N
Sn the bast,for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
G applicant for a permit subjects the applicant to a civil penalty of not more than
.five hundred dollars($500). NEW RESIDENTIAL ELECTR
F11,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
k7 compensation,wilidothework,andthesttucture Isnot intended or offered for
5 ❑ sale(Sec.7044,Business and Professions Code:The Contractor's License law
does not apply to an owner of property who Wilds or Improves 1M1ereom,and ROUP RES.UNITS
0.0. whodoesauchwork himselforlhrough hlsownemployces,provided that such
improvernena arc not intended oroffered for sale,l(however,thebullding or TOTAL-
Improvement lssold within oneyearofcompletion,the owner-bullderwill have
itenolpmving that he ala not Wild mimprove for purpoaenfsale.). QTy. {,} !'),PLUMBING`PERAIXT 'FEE " FLOOD ZONE APN
trowner of the,property,am exclusively contracting with licensed PERMIT ISSUANCE
j rontracton to construct the project(Sec.7044,Busineasand Pmfeeslom Code; C1.21 00
The Contractor's License Law does mot apply to an owner of property who ALTER-DRAIN(4 VENT-WATER(EA) '
Wlib be Improve thereon, and who contracts, for such lupfects with a q 'FEE SUMMARY, l
c7a4a.eector(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJI am exempt under S . 0 k P for this meaon
Owner: Date DRAINS FLOOR ROD IFAREA,'COND. - SANITARY .Y N_ '
RECEB'rIt
-WORKMANCOMPENSATIONDECLARATION FIXTURES.PER TRAP SCITOOL TAX Y_ N
��}}{{��ereby affirm that I have a mrtiRcate of consent to self-Insure,ora RECEI Nx
/ cea�(I,Lab
rken'Compensatlonlsuuranm ora certl(kd mpy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y ' N_
PolicyYb C.) D .aJ 00 ,30 n •3 RECEIPT It
GAS F.A.SYSTEM-OVER 4(EA)
Co�panv JQ BUILDING DIVISION FOES
I =11ed ropy is filedwhereby th the cityIed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy Isfiledwith us city InspMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM FA.700Fr. Date Recei tin
. -„ (!his seniors neetl eat be completed lithe permit Isfor one hundred dollars
($1(1(B or less) WATER HEATER w/VENT/HLECTa ENERGY FEE Y N_ .
I cert lythat in the performance of the work forwhkh this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SY9311M/TREATING
Workeri Compensation Laws of California. Date PAID
O Z Applicant NEW RLS DPN RAL PLUM._SQ,FT. Date Recei tI
r z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,You
should become subject to the Workeri Comperuat ion proubdom of the LaWr TOTAL:
2 N Code,you must forthwith comply with such provlslons or this permit shall be -BUILDING ••E '
W > deemed revoked. -
a r'0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC
TOTAL: r)
0 Z anceo(.Nwork!or which lhIs permit Islssued(Sec.3097,Clv.Cd I GV
LL O Lemder's Name PLUMBING FEE Q
F lenders AdhatI - QTY. ,'' 'MECHANICAL PERMIT ' FEE t
O W Icedify tagreet complhbappBcitlond utatyordiheaboveinformation MECHANICAL FEE
S la rormn.7agreeto complywith all city and rountyordlnancee and slate lawn PERMIT ISSUANCE FEES PAID:
-} relating to building construction,and hereby authorize representatives ofthis
(— N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Receipt#
V a ainstllabllitles, d menti,mets and expenses which may in an wa acerue AIRHANDLINGUMT CrOI0,000CFM)
- g w B Ix Y. Y Y �. SUBTOTAL:
sgainst City In mese.Tuenm of the granting of this permit. -
(/"J AIR HANDLING UNIT(ovEx 10,000CFM) CONSTRUCTION TAX
Signature of Applicart/CoottActor Date / e%HAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thea applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) .
FF P
maleiui as defined by the Cupertino Municipal Code Chapter 9.1Z and the Date Recei ted
Health and Safety Cod e,Fon 2M37(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: rO
❑Yes t/6�,N
Will the applkan r future building occupant use equlprnent or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE '
- whichemit hazardous air contaminants as defined by the Bay Area Air
Quality hfavgement Dish- - - BOILER-COMP(3TIPOR 100,0010 BTU) IZLL"
have read the hoz ow
rials Sect ions
2under 553aChapte4.I of BOILER-COMP(OVER 100,000 BTU)
theerstandt at lithe Safety Code, of torertly h ,,.tmnd75hat It A/aakkk Q
respntand that notify
the ing occupant of therequirments which
that it is my NEW RESIDENTIAL MECH. SQ.FT.
resporsib0ityto natty theocmpant of the rcquiremenbwhich must be rtret e•
- prior t....�(�(ppss� anef�f a Certifiestcofoavpancy.
Owner or authorized Ogent Date TOTAISSUED
L
OFFICE COPY `