21131 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 1 �?- 1 PFRh9T NO.
Building Address: d` L / 21131
0 �( LRIj 3 C2GV
rune,, a one; APPLICATION SUBMITrAL=
r/� 1 V-'v- p CITY OF CUPERTINO-BUILDING DIVISION
' k1%eQNa-/q'�e�' ILl[e. APPLICATION I PERMIT �� —9�
lse-a`7y � -3 5�`��1 BUILDINGELECnUCAL PLIIMBINGMECIIAMCAL CATEGORY CONTROL X
Arch��ltaaqg/��nngqiiyyeeqq—� r�F� LIG.N
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISUANCE
LICENSED ED CONTRACTOR'S DECLARATION LSI
Ihereby
ectionaffirm that[ iv licensedoftheIunder p essand odessi. .0 de,amen< APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith1.1.Section )of Division ltheBugneu�I'rolesgonsCode,andmy �����
license is In full end drect. (II.�� rANELS
EcLjoaLca _
Date7ContraRor _a -
ARCHITEC'SDECLARATION 201-1000 AMPS
^tt0 Z Licensed Professlorul SIGNS ELECTRICAL I understand my plans shall be used u m
public rerde. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
0G
6 OWNER-BUILDER DECLARATION ��1
7��2.& y SPECULCIRCUIT/MISC
I here6 afBmn that I -HO from the DECLARATION
Llttn.Law for the
qQ following recon.(Section 70315,Business and Professions Code:Any city or
Fs'ul county which requires a permit lomutroat,alter,improve,demolbh,orrepair TEMP.M=OR POLE INST.
3 anystmMmpriortoiblswance,aborequlrealheapplluntfenuchpor tto POWER DEVICES
file a signed statement that he is Bcense,pursuant to the provisions of the
: F. Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWBWNG POOL ELECTRIC
F, OJ cion 3 of the Business and Professions Code)orthat he Is exempt therefrom and VALUATIft
f5 G 5. the lauds for the alleged exemption. Any violation of Section 7m1.S by any OUTLETSSW[TCFICSF!%TI1RF5 Gk, ((r'1
yg�O
applicant permit
ntfor. subjects theapphunt tad civil penalty of not more than l �G('
$ Bve hundred dollars($SM. NEW RESIDENTIAL ELECTR STORIES / TYPE CONSTRUCT ION
�00f �n I,as owner of the roe `"Q'FT•
p p rty,or my employees with wage as their sole
C$
mmpeneatlon,wllldothe wwkgw
end thecture boar interned or offs r O
Is(Sec.7014,flushLess and Prefoadow Code:The Contractor's Lim w
iK $ does not apply to an owner of property who build,or Improves th Rand
E who doessuchwork himselforthrwgh hheownemployees,prov, ed thatwch OCC.GROUP RFS.UNITS
Improvements are not intended oroffered forule.If,hmve,e ebuhlding.r TOTAL: OI
Impro =ntbwldwithhnoneyearofcomplmtb theown ullderwlllhave
tli�Jfurcien of proving that he dM cot build or improve purpouofuls.). QTY. PhWBING PERMIT FEE FLOOD TONE APN
Lj L as owner of the property,am exclusively m ,acting with licensed PQ2MLL I5SU E ,y
contractors to mutruct the proper(Sec"
7614,Bull and Prefessi..Code: {y
The Contractor's Llcenne Law does not apply to no—
or property o ALTER- IEA)
Wilds or improves thereon, and who cont •for wch p(o)ccts wit -
c'gLLI ctor(g Bunud Naream to the Contra •Llan.Law. gA TELT.DEV FEE SUMMARY
I__I I am exempt under Sm B k P C far 1h
Owner DRAT RROOF,A GOND. SANITARY Y N
Data RECEIPT p
WORKMANI have. 9 TION DECLARATION FD('IURFS PER TRAP SCI{OGL TAX Y N
❑I hereby affirm that I have o IRute of consent to.B-1 a RECEIPT M
Owner of Worken'Comperoatlo ..am ora certified t (Sec.
3800,Lab C.) AS EA.SVSTEM•1 INC. UTLETs PARKFEE Y_ N
Policy Y GAS-G.SYSTEM-OVE 6(G) RECEIPT N
Cc������mPPPPPPany BUILDING DIVISION FEES
�Certlried rop:::S
rum had. GREASE/INDUSfAI. ASIS INTFRCQP70R PL N -IECK FEG
Certifisdmpthtl city Wpection division.
CERTIFIN PTION FROM WORKERS' GREASETRAP PAID
_ Te INSURANCE SEWER-sANrf -s1DRMG 200FT Dale Recei t#Rhb.sctl.n nemplgedl permitbforuns hundrrtd dollen(Stro)orleu.) WATER FLEA W/VENT/ELEOTR ENERGYFEE Y N
I ondilythat In t ..of thew., rwhlchlMspemnitisbausd,
I shall not employ In any manner to become wbjett to theWATQt TFM/TREATINGCompeno(GII(omb.Dale PAID
O Z Appilunt R69DLNTTAL PLMB. SD.PT. Date Recei t#
Z O NOT/CE TO AIRPLICANT:B,after making tib Cartifluleo 1lon, ons
should become subject to the Workers''Compewtlon provbi.0 oft a r TAL:
W Code,you must forthwith comply with such provhlouor this permit shall be D D Waco
deemed revoked.W p coNsrllvrnoN LENDING ACExlcv SEISMIC FEE
dI herebyaBimtlhatlhere b a construction lendingagenry farthe perform ELECTRIC FEEZ once of the workfor which tib permit bloomed(Sec.3097,CIv,CJ TOTAL: q i
U O lender'.Name a+l PLUMBING FEE O a
U. F- Lend,e.Add.. QTY. MECHANICAL PERMIT FEE MEC f-1 CAL • 0
O 111
lc Alfythmlhavemaathlsappliutlonanddatethattheabovelnfornutlon ,a .x..
C brr
mect.Iagreeto comply with all city and muntyordlnanms and gate laws PERMITLSSUANCE 2cW P AID:
Y N relmingtobulldiagmutwction,and herebyanthorizempremntathmc,fthl.
H U) city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. 1-0
— (W e)agree to ve,IndemNly an d harmless the City of Cupertino a ec 1 t#7j Ql
agalnsthabllltl dgments, es a en which maylnany aye a MRHANDLNCUNrr(TOIOMCFM) UB TAL•
agai 1 y In con gra g of this pemdt.
/ AIR HANDLING UNIT(OVER 10,000 CFM) FAX
igutureofA est/Contractor c EEXRAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATE RIA LS DISC OSUR
Willt applicant or future building ocmpanblore or handle hazardous HGTINGUNIT(TO100,0000TU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Hullh and Safety Code,s-Snection 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 yes II No
Will the applicant or future building occupant use equipment or devices VPNTIGTION FAN(SINGLE RESID)
which emit hazardous air contaminants an deflned by the Bay Area Air
Quality Management District? BOILER-COMP CH POR 100,009 BTU)
4Yu ❑No •1
have rea the Health&Safet materlab requirements 255 nh undeand 2553 .1 BOB ER-COMP(OVUi 1 W,000 BTU APR 1 1991
the Glifornb Health k Satiety Code,Sections 25505,75533 and 2:534.1
undsrstandthat if the building does not currently have a tenant,that it bmy NEW RESIDENTIAL MECFL SQ.1T.
responsibility I.notify the occupant of the requirements which at be met slfAsea_COB,
prior to luuarea of a Certificate of Occupanry.
Owner or authorlud agent Data ISSUEDBY.
TOTAL: l
OFFICE COPY