21333 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identlfleatlon PERMIT NO.
Building Address:
Z3��Z �JssPW �, �D CA— C7so 2133
Tywneva /one:
("t IQ 512�� (A))--'I —1 -L CITY OFCUPERTINO-BUILDING DIVISION
Contractor's Name: W)Syly ue.jN4_ APPLICATION /PERMIT QL
BUILDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CJd�tQL17—
A Its&/egi 0 c g6 q Etc.No: CJod�J
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: i I P x A� S, .fPLRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provedonsoitChapterg(commene, APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwitleSection 7000)Of INision3ofthelluslnessand Pro(esslonsCde,and my
license ismLicerseClass (arae and ic.itt PANdS TC' J pro plI e
Date Contracts.
ARCHITECTS DECLARATION 20-1000 AMPS
oc 2 7 understand my plain ehaB be used es public records OVER IOW AMPS SQ.FT.FLOOR ARG S/SQ.FT.
Licensed Professional SIGNSELECTRICAL ® I
�6
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC ^�� -^
og�3 Ihercbyaffirm that]amexemptfrom the CnlractoreLl¢nseLawlwthe III, Ifo
2 following reason.(Section 7031.5,Business aM Pnefenbns Cade:Any city or TEMP.METER OR POLE INST.
�� county which requires a permit to ronstned,alter,improve,demolish,Ormpair 9 / J ap
anystmc mprlortaittsoame,atorequlreslheapphcantforsuchpermitto POWER DEVICES �T/�"' 7
ryC file a signed statement that he t licensed pursuant to the provisions of the TE -
3p� Contractor.Lksme Law(Chapter 9(commencing with Section 7DIN)of Divi- SWIMMING POOL ELECTRIC `--
Mon 3 of the Business and professions Code or that he t exempt therefromand VALUATION
S the basis for the alleged exemption.,Any violation of Sectlon 7031.5 by any /
CS applicant fora permit subjeRstheappllcanttoa civil perukyofnot morethan OUILE'1SSWf717HFSFIXTURES
k",asrewnerdollars the EK
pro NEW RESIDENTIAL ELECTR_SQ.Fr. STORIES TYPE CONSTRUCTION
7< I, saowner will
the property,or my employee with wages r there sok
coin ns 700tion,Business
k desand theetrude:T e Contractorot or...L .
or
O dale(net 7074,to alnow owner
f property
Code:The Contractors License Law
doe net apply torn ownerorpropertywhobe lids nemple Improvethereon,and OCC.CROUP RFS.UMTS
CF
who do's
mentsa orktintenedm through hleowele.If oweveovhded ebuildtach
Improvement am not Intended carofred plinfo.ILhower-b deer ldl have TOTAL:
Improvement tsold within oneyearofcompl&lon,theowner-bulWcrwN have
tl)F.tiurden of proving that he did rot build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
metra&--to construct the project(Sec 7074 Busmen and Professions Codr.
The Contractors License Law don not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
W
Wilds or Improve thereon, and who comment for such ptojecs with a
mp(ra&w(a)Binned pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Ll l m ext 7pt under Sec. B&P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date 9� RECEII'1'p
Q �W k1UMfA UMPENSATIONDECLA ATION pp(T,URES.PER TRAP SCItODL 7A% Y N
I hereby affirm that I have a certificate of consent to self-Insure,w a RECEIPT N
380l(Icab o(Worken'Csmpensatlonlruurance oracertBled copy therm((Sec. GAS.EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
mAlf Isis of
Colmty n GAS EA.SYSTEM-OVER 4(EA) RECEIVE N
Z BUILDING DIVISION FEES
CcAEedified copy le hercbyhthcity
furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Cenl(led copy t filed with the city Inspection division.
CERTIHGTEOFO(EMPTION FROM WORKERS' GREASE TRAP PAID do U" V "
COMPENSATION INSURANCE SEWER-SANITARY-SMRMEA20017' Date Recei t#
Qhlne
'Ing.) M rad becompleted If the permit tfuran,hundred dollars
(SIW)aifyth WATER HEATERW/VENT/ELTCTR ENERGYFEE Y N
I¢rtlfythatlethe pe&omun¢afthe work(orwhlch this permit is Exceed
I shall not employ any In any manner ao v to become subject to the
Workers'Compensation Laws
aws o(Celi(ornt. Date WATER SYSTEM/TREATING PAID
O Z Applicant NEW RESIDENTIAL PLMB. Date Recet !�
Z O NOTICE TO APPLICANT:ILafier making this Certificate of Exemption,you —SQ.FE
Fshould becomesubkd to the Worker'Compensation provisions ofthe Labor TOTAL:
IL N Code you most forthwith comply with each provisions ortht permit shall be BUILDING FEE •�
deemed revoked,
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE 'b
]hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
�.Z once.(the work for which this permit is Issued(See.3097,Civ.C.) TOTAL t
U O Lender.Name PLUMBING FEE
IL )- Lendersnddress QTY. MECHANICAL PERMIT E MECHANICAL FEE
O W Icertifythat l havereadthtapplicationand natation the above information
a Incurred.Iagreeto comply with all city and county ordinances And gate lawn PERMIT ISSUANCE FEES PAID:
>. relating to building mrstmctl-n, red hembyauthodze representatives it
F Z
city to enter upon the abcvemennoned property for inspection purposes. ALTERORADDTOMFCH. Date Recti t#
V — (We)agree to save,Ind emNfy an d keep harmless the City of Cu pen leo
Against liabilities,judgment,ons.and expense which may to any wayaocrue AIR HA NDLING UNIT(To 10,000 CFM) SUBTOTAL:
againstat Cyy�roe�quen¢of the granting of this permit. r
1-11 /1 k,�_�- ,A0 AIR HANDLING UNIT(OVER l0,W0CIM) CONSTRUCTION TAX
pA SIgnSNre of A�VplF•ntt//Coonttructor Date 1 E%HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:,
HAZARDOUS MATERIALS DISCLOSURE
Waltheapplicant or future building occupant store orlundle hazardous HEATING UNIT CIO iW,000 BTU) Date Rttei tq
material as defined by the Cupertino Municipal Code,Chapter 9.I$and the
Health and SafetyCade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTIA TOTAL: 6 s
❑Yea No
Wlllthe Applicant- tuns building occupant use equlpr¢nt or devices VENTILATION FAN(SINGLE RFSID) 4U ; G DATE
/'r*
which eon hazardous air contaminants as defined by the Bay Area Air �a ISSUA
Quality Management District? BOILER-COMP 0HPOR 100,000 BTU)
4Yes was NOV U2 7990
have read the hazy ossa materials requirement under Chapter 6.95 of BOILER-COMP(OVER 700,000 BN)
the California I lealth&Safely Cade,Sed lora 75505,2573 and 75534.I
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQFr z
responsibility to notify the ompa nt of the rcqu Imment which moat be mel N., Pf(el q
prior to tsuanc b aCrtl ateofOauEI / Culp L� yr,nA
�a�A l u � iii
Ownhorauthoriza agent Da ISSUED BY: III ure 44
TOTAL:
OFFICE COPY