21785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PFRMTNO.
oundlag Addren: 21785
'9 a� 1'J^r
0340 �a/ �► i t G I I l8 VM
wnere ante: one:
., CITY OF CUPERTINO-BUILDING DIVISION I ^e2p^Q I
cono-ador'a Name: Lk.Na: APPLICATION If PERMIT I II
Architect/Englncer: Lk.No:
B(ILDINC-ELECT'RICAI.PLUMBING-MSCI IAMCAL CATEGORY CONTROL k
�s 0QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address' `O,jt� �,� JA / O✓ . e PERMITISSUANCE El ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
lbareby affirm that l am licensed under provWonsof Chaptarl)(commene. APPLIANCESRESIDENTIAL - JOB DESCRIPTION
ingivitlicen.h Sect fon 70W)ol Di effect lthefuslnenand ProfeeNona Code,and my _ �-•,' `c n �'1 )L+
li38nse le In tion f roynd dicot PANELS �NJTrY O✓{r_
License Chas c Lt.N S-G G 7 G'
Dale Contractor A Ali /a Ga.
ARCHITECTS DECLARATION 201-1000`DIPS
pkp�vv W ro. I understand my plare shall be used as public records. . OVER IOW AMPS SQ.FI.FLOOR AREA S/SQ.Ff.
Fi Z! Licensed Pra(eaelonul SIGNS ELECTRICAL r y
<6 OWNER-BUILDER DECLARATION R r n �� i
C SPECNLC RC IT/M SC j L' V
Zt, owingHoarereason.
of..731.5,Bat I am Busrom h.
Contractor's License law fort he
following reuses.(Section 70315,Business and Professions Cade:Any city or
O j. TEMP.METER ORIOLE INST.county
P� anystm hkhrequlresa toltsi rmlttoalsore uimth,lmpmvgdemsuch, esepals
any atmcture tatementsluuaneis alcensed rersuant to the rovoilomof t e POWER DEVICES
ryG fie a signed statement that helicensed pursuant to the Section
) of the
30r^ Contractor's3fth. .imess law(Chapter9(commerW with SectWn7.refra Diel- Hit LLL
tlon3otthe Buainmeand laroiebru Code)orthagheberem therefromand SWIMMING POOL ELECTRIC 7ION
P' 6 the basis for the alleged exemption. Any violation of Section 70313 by any OI17LE15SWIT'CFIES}TXIURFS
applicant fora permit subjecu theappfcanl to a civil Family of out more than
five hundred dollars(¢500). NEW RESIDENTIAL ELCCIR
❑ ❑I,as owner of the property,or my employees with wages as their sale _S'2'.IT.
STORIES TYPE CONSTRUCTION
compensation,"I do the work and the structure h not Intended or offered for
Osale(Sec.7054,9usineas and Prafesslors Code:The Contrad.e.Limue Law
docs.m.pplyto an owmr ofpmpeny who builds orlmproves thereon,and OCC.CROUP - RES.UNITS
EE whoduessuchworkhlnselforthrough Nsownemployees,provided that such
improvements arc not Intended oroffered for sale.If,however thebuildingor TOTAL:
Improvement issold wlthlnoneyearofcompldiorytheowner-bunderwlil have
t1p*rden of proving that he did net build or Improve for purpme ofsale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm.7044,Business and Profculoru Code: PERMIT ISSUANCE eY,
The Contract �1or's Llccnn Taw does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA) 11 CV
builds or Improves thereon, and who contracts for such pW*U with a FEE SUMMARY
crjp(lactor(s)Bceved pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICEI_l I am exempt under See. B&P C for this mason OUTSI
ITES
DRAINS.FT-ODR ROOF,AREA,COND. e1�0]} SANITARY Y N�
Owner Date RECFRTN
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N_
❑1 hereby.(firm that I have o certificateonrarm at consent to copy
them. (S a
3800ficate,L.bo(Werkere'Compeuatlonluurance ora certified ropy thereof(Sec. GAS-EA.SYSTFA47 INC4 OUTLETS PARK FEE Y_NN
3BW,Lab C.)
Policy MRECEIPT It
' GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DI VISION TEES
Certified ropy bi herebythe ed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy h filed withth the city inspection dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM IIA.200FT Date Revel HI
(Thlssedion need rad be completed If the permit Is fm one hundred dollars
(S]W)orfy that
W) that In the performance of the work for which this permit hBound, WATER HEATER W/VENT/ELECTR ENERCYFEE Y N
I shall not employ any person In any manner an u to become bpd to the WATER SYSTFSd/TREATING
Workers'Compe cation L.wa of Call(pTd3s Date� AT— �� PAID
O Z ApplicanTo � XEr NEWRESIDENTALFLMB._SQ FT. Date Revel [N
Z O NOTICE TO PLI :1L after making this Certificate.(Ezemption,you
Hshouldbecomesubjectt.the Workers'Compensation provision oflhe Labor TOTAL:
fq Code,you must forthwith comply with such provfebu or this permft shall be BUILDING
W deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL C I hereby affirm that them is a cerutrudion lending agency for the perform- ELECTRIC FEE
7 Z once oflhe work far which this permit is issued(Sec.3097,Civ.C.) TOTAL: �(.,Yx
V O Lend.e.N.me PLUMBING FEE
LL ~ Lender's Address QTY,I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatlhavemdthbappbmtfonando4tethattheabovelnfornatfon
6 Incorrect.l agmeto comply withal!rllyand county ordinances and pate laws PERMIT ISSUANCE FEE_PAID'
>. IA misting to building mratrudlon,and hereby authorize representatives ofthls
F U) city to enter upon the above-mentiorad property for bupWlon purposes. ALTERORADDTOMECH. Dale ReCCI f#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,pdgment.,antis and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against said City in consequence of the ting of this permit AIR HANDLING UNIT(OVER 10,000CTM) CONSTRUCTION TAX
�61ghatumo Appli radon - Das IXHADS'T HOOD(W/OLIGO CONSTRUCTION TAX PAID:
HAZARDOUS
RDOUS MATERIALS DISCLOSURE
Will al as appned by
futurebuildinggnicipan ode, hhand9.hazardous HEATING UMT(TO 1W,000 O1U) Date Recel [p
materialas Safety bythe Cupertino Municipal Code,Chapter 9]2,and the -
IiealtgandSa(sty Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTN TOTAL: -d(]
RNoYrs
llltheapplicantor stare building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q�jalfty Management District? BOILER-COMP OFR'OR I W,O(U TITLE)
haYnF�N
vee.reazai�ouad the hs omrequirements requlnbunder Chapter 6.95 of ROTI-ER-COMP(OVQtIW,OW BTU)
the2".illfomla Health&Safety Code,Sections 25505,25533 and 25534.I
understand that lithe building does not comenlly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requirements which at be seat O s_iv
prior to Inuance of a Cedlficate of Occupanry.
Owner or authorized agent Date ISSUEDHYivk mss"
TOTAL:
OFFICE COPY