21111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY or i
Building ProjectldendfkatlonD PRItMITN21111
Building Add 1 ^ A
0 3 1 .e
wnef s one: p
G-Q.auf CITY OF CUPERTINO-BUILDING DIVISION i o—L_•qO
• c lite °r'N/p' //I
Lie m APPLICATION I PERMIT
r ••, BUILDINGELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL#
N QTY ELECTRIC PERMIT {.yg BUILDING PERMIT INFO
Address PERMITISSUANCE � Imo'
LICENSED CONTRACTOR'S DECLARATION D1
I hembyafflrmthal l am licensed under provlslomof Chaptee9(co.an APPLIANCESRFSIDENTAL JOB DESCRUMON
ingwith Secilon70N)of DiWslon3ofthe Bugg a fesslonsCode,andmy
license isin fulkPim and d(ect. *q r.OG/N PANELS
Liar �rsr ^w`
Llmnec Ch �]/OJ, I Y— U
Date� �� C.ntraRor
ARCHITECPSD CI.ARATION IDI-1000 AMPS
OZIunderstand my plans shag be used n public records OVERIOOOA.MPS SQ.FT.FLOOR AREA $/SQ.Fr.
zzobgg� Licensed I'mfesaloml SIGNS ELECTRICAL Q// O
res< OWNER-BUILDER DECLARATION SPECIALCdtCUIT/MISC -
a m Ihereby affirthat l am exempt from the Contractor's License law for the
Z following reason.05actlon 7031.5,Business and Professions Code:Any city or 1 O
TEMP.METER ORPOLE INST.
cwntywhkh requlrtea permit to coiutmci,alter,lmpmve,demoldh,armpalr
anyetmelurt prior[.Ih Wuame,Wo roqulrestheappBunt(..such permit to POWER DEVICES
0 file a signed statement that he is licensed pursuant to the prov4lons of the
�wl- Contractor'sLimmelaw(Chapter9(mmmencingwlth Senkn7000)of DIW- SWIMMING IDOL ELECTRIC
�O sion3 ofthe Bustnessmd Pmfesslom Cede)mthat he V exempt therefromand VALUATION
< the basis for the alleged exemption. Any violation of Sectio"7R)1 S by any OUTLETSSWITCFTESFIJCTURFS d 66
appRcant for a permit subjects the applicant to a civil penalty of not more than I ti yti ' /�11_a
five hundred dollars(5500). •, v s7 "�
NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my empkyces with wages a thele sole 9QE7' STORIES TYPE CONSTRUCTION
compensation,Duadatheworr famionand ructum is not Cte.:Th.Cmdra oe o,offered
maisfor /LO CT
.1.es(not pply to sbten and f property
rope ty Co build,Contractors Llttme lad
does oessucy loan imsero(throug ywho nemporlmprovmthereoRand OCC.GROUP RES.UNITS
C.: whodoements are nor mselfedorough hlsowne.If,ho ee,p , ided thebthatsuch [�
Improvements withindneyear fcompered rsale.7l, crweveg alder ill hang ve TOTAL; J0
Improvement Maold within one yearof complMioa the ownervbullderwlll have
tliLkurden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
u FLOOD TONE APN
I,as owner of the property,am exclusively contracting with is Codd PFRMITISSUANCE
contractorsct construct the w doe(See.of apply
Busmen and Pf pro ons Code: vJ
Wil s or improves
License Lw does not apply to an owner d property who ALT EWDRAIN&VENT-WATER(EA)
Wilds or improvee tpursua and who contacts for such p okm with a
cpypctor(gempt pursuant to the Contractors Llmnse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1 am exempt under Sec. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� -
. Date RECEIPT M
WORK MAN I have
DECLARATION �.N PER TRAP SCHOOL TAI( Y N
❑I hereby Affiorkern that I have o ce lAcamInsurance
of consent to copy
theure,ora RECEPr#
re00,I.eo(Workeri Compematlonlnsurance ora certBled copy thereof(Sec. GAS EA.SY -1
Polis Lab C.I RK FEE Y_ N_
1'ollry p RECENT M
Com any GZ�•'� 4 nU1LDING DIVISIONFEES
ffCedUed copy V hereby kmiMad. GREASE/IND L NCHECK PEE
❑Certified copy is filed with the city inspection division. �♦
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP DA PAID II`
COMPENSATION SEWER-SANITARY-S10RM EA 200Ff Date Recei I# 1 3OD
Ohd section need not be completed](the permit b(.mons hundred dollars
(8100)orless) WATER HEATER W/VENT/F1 TR ENERGY FEE Y N
I cent em t in the performance.(the work fo A,to b this eennn c issued,
I shall not employ any person in any manner at n to become subject to the
OWATER SYSTTN/TREATING PAID—
Applicant
Workcri Compenutlon Gws.1 California.Date
Z
NORCceI t#
Z Z NOTICECE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLM H. SQ.FT. Date
Hshould become subject to the Workers'Compensation provisions of the Labor T FEE TOTAL:
f7) Coda you at forthwith comply with such provisions.,this permltshall be 1
deemed revoked. provisions.,
G
ILC CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby afRrmthat them Vs construction lending agency for the perform ELECTRIC FEE
:3Z once ofthe work for which lhlapermlt b laued(SM 3097,C1v.C.) TOTAL: l
00 ]Anders Name PLUMBING FEE
LL F- Lenders Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icerti(ythat l have read this appllcetknand statethat theabove Information
a kcorreci.I agree to complywlthall dtyand county ordinanes and Mate laws PERMIT JIQ FEES PAID:
} W relating tobullding mmtmctlon,and hereby authorize representatives ofthM
tZ atymenterupon the abovcmentl.nul property for Inspection purposes. ALTERORADDTOMECH. Date
(We)agree to As 1 emnity an keep haemic the City of Cupertino Receipt
agalmtllablll s,N
Zen= espenxe ma anywayaocrue AIRHANDLINGUMT(TOIg000CFM) SUBTOTAL:
agaWt ronaequen he gent • It AIR HANDLING UNIT(OVER IO,ODOCPM) CONSTRUCTION TAX
SI azure. Appli / nivctor t U'(HAL'ST}IOOD(W/DUCT) CONSTRUCTION TAX PAID:
A2ARDOUS MATERIALS UISCLOSU E
Willthea Iennl or future budding onvpantstore or handle hanrdous HEATING UNIT(T0100,0E0 BTU) Date RCCCI
material as cieflned by the Cupertino Municipal Code,Chapter 9,12,and the ---
flealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTL B TOTA
LlP
❑ Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit haurdous Ar contaminants as defined by the Bay Arca Air
Qu a lily Management District? BOILER-COMP OHP OR 100,003 BTU) p 6 O
4 Yes 4 No
havemadthebaza ossa materials mqulnements under Chapter 6.95 of BOILER-NMP(OVER100,000BTU) nN
the California Health&SafetyCoda Sectkrmm 25505,25533and 25534.1 JAM
5 understand that if the building does not motly have a tenant,that It Is my NEW RESIDENTIAL NIECE 1. SQ.FT. AM 19999
responsibility to notify the occupant of the roquirerrcnts which must be met
prior to Issuance Of a Certificate ofO=pa ocy.
Sb—
Owner.r authorized agent DateISSUED BY:
V Vt'�ffl W lv a"�.1.
TOTAL: I O
OFFICE COPY