21249 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addreesss: /+ a2 21249
wnel.I .me; 5 3 6o /n '�ye Gag.,,
?. Alz CITY OF CUPERTINO-BUILDING DIVISION
AMContractor's Name: Lie,No: . APPLICATION /PERMIT
IL BUrLDING-ELECTRJCALPLtWBINGMWTAMCAL CATEGORY CONTROL If
IN Arcbitect/Engine Lie.No:
01Y ELECTRIC P M FEE BUILDING PERMITINFO
Address: PERMIT ISSUANCE •W ❑ ❑
LICENSEDCOISTRACTOR'S LA
DECRATION
I berebyafflrenthxt lamlicense!under provislonsof Chapter9(mmmenc APPUANICESRtfflDEV&L JOB DFSCRBT70N
license
i7000)of Divlon
sl3 af[he Buslneasand PmfesaloneCode,and my as, ^ e..t
cersel i islesHonfull(o and effect. PANUS
License Clam Lic,s_ S/ a.
Date ontrat or a
ARCHITECI.5 DECLARATIO2201-1
an ZO I understand my plate shall be used as public records. OVER 1 SQ.FT.FLOOR AREA $/SQ.FT.
hi U Licensed Profemlorel SIGNS EL TRIAL
OWNER-BUILDER DECLARATION SPECIAL I PSC
2 s"�G I herebyalRrmthal l am exemptfmen the Contractor's License Law for the
OR-qpp f011owing maw,(Section 7011.5,Business and Professions Code:Any dty'or
countywhichrequlreaaperMttommtmO,atter,tmprove,de=Ush,orrepair TEMP.METER POLL•INST.
q� anystmc mpdorlaits Wuameaisomquimstheappllesntforsuch perndtto
E 1
fila a signed statement that he h u
licensed poi to the provisiom of the POWER DEVICES
06Oµ Conlraeors License law(Chapler9(mmmenWgwith Section 7000)ofDivi.
1,,,30 ow3 of the Businnsand ProfenbruCode)orthat heisexemEntherefromand SLVBe1MINGPOOLELECIRIC VALUATION
Sh'g the bash for the alleged exemption. Any violation of Section 7011.5 by any 72., Sb
p5
applicant for.permitaubjeits the applicant to a civil penalty of not retro than OUTLETS-SWITCHES-FIXII)RE5
five hundred dollars 000, NEW RESIDENTIAL ELECTRSQ.FT,
Z�n ❑I,as owner of the pmperty,or my employees with wages,as Iheir sole STORIES TETE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
Osale(Sec.70K go.],and Profemima,Code:The Contractor's Lt..Law
�$ does not apply to an owner of property who builds or Improves l hereon,and OCC.GROIIP RPS.11NIT5
whodoeaeuchworkhimself orthrough hisown employees,provided that each L3
improvements are not intended oroffeyed forsale,If,however,thebuildingor TOTAL: IEZ
improvement issoldwlthln oneycarofcomptetion,theowner-bullderwill have '
tb&rden of proving that he did not build or Improve for purpose of sale,), QTY, PLUMBING PERMIT FEE FLOOD ZONE APNr
�,J L as owner of the Property,am exclusively mmmtling with licensed ppnMlT ISSUANCE
contractors to mnslruct the project(See 7044,Business and Profembre Code:
The Contmoori Llcemse law does not apply to an owner of property who ,Q DRAIN k VENT WATER(EA)
builds or Improve on
there ,and who mntncta for such p(ojects with a • FEE SUMMARY
conactor(s)licensed pursuant to the Contruchm's License Law. BACK FLOW PROTECT.DEVICE
L�I am exempt under Sec. B 4:P C for this maven
DRAINS FLOOR ROOF,AREA,CONTI, SANITARY Y N
Owner Date RECEIPT g
E/
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI100L TAX Y N
IJt hereby affirmorker thaco I have a mrti0ate of consent 10 op thereof
ora RECEIPT If
owneraleal Worken'Compewtlonivurance oracertified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS -
3300,IabCJ !/ PANK FEE Y N
Pd H 7 •— _ RLCmr'f M
Com an GAS (G)EA,SYSTEM-OVER - BUILDING DI VISION JE CS
I ICerllfled copy la ercby(ur���tttbhn�dd GRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
LTJ Cerlllicd copy Ls(fled with the dry W pection diviflun.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWrF-I(-SAND'ARYSfORM EA.200FT. Date Revel !N
Uhor Ims) need eat be completed If the permit is(Drone hundred dollars
(5100)Imrttfy that
WATER I rEATER W/VENT/ELECTR ENERGY FEE Y N
lcertlfy that In the performance of the work for whkhthb permit la issued, —
Ishall not employ any person In any manner n m to become subject to the WATER SYS.I.FM/.TREATING
Workera Compematlon Laws of Gllfomfa.Data. PAID
-
zZ Applicant NEWRESIDENTIALPIMB, Dale Revel IM
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you `SQd'T•
Hshould become subject to the Workers'Compensation provisimuofthe Labor TOTAL:
Code,you=at forthwith comply with such provisions orthh permit shall be O,
O
> deemed revoked. •NG • •
ap - CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyalflrenthat there is a mmtruction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
V 0 Lender's Nan, PLUMBING FEE
LLF- Lender's Add mm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Is correct.IwAffythall have read this applicallonand alatelhat the above Information
Iegreetocomplywlthall cilyand county ordinances and atatelaws PERMIT ISSUANCE FEES PAID:
}
W n relating to building construction,and hereby authorize representatives of this
F. city to enter upon the abov .htIwrd property far Inspection purposes, ALTERORADDTOMEOH,
? (We)agree to save,Indemnify an d keep harmless the City of Cu pertlno Date Reeei t#
against habl0ties,)dgments,mats and expenseswhich may manywayacence AIR HANDLING UNIT(TO 10000 CFM) SUBTOTAL:
against Pty con en ohhe granting of lisle penult.
J-4d AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
si of pplicant/Contractor Data EXHAus r How(W/DUCT) CONSTRUCTION TAX PAID:
'HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or future building occupant store or hand le haramous HEATTNG UNIT(TO 100,"BTU)
material as definedby the Copan]no Mu hid al Code,Chapter 9.1 Date Recei tN
pe p in 2,and the
HealthYea Salcty Cade,ss yea�won 25532G)7 HEATING UMT(OVER i W,000 BTU) TOTAL' V(7
❑Yes . ;• Ld'Nre
Willcoal appliluccar ousairnt or co building nants ocmpant usedby equipment or the Bay Area
VFN77LAI70N FAN(SINGLE RESID) ISSUANCE DATE
which emit h'gemo us,air contaminants as defined by the Bay Area Alr
QuslitY KdnagemenI Dist id? BOILER-COMP OM'OR 100,000 BTU)
4Yes
havaread the hazy ouamaterlals requirements under Chapter 6.95 of BOILER-COMP(OVER 1(0,000 BTU)
the California Health h Safety Code,Sections 25505,25533 and 25534, I OUT Y all
underatandil lifthebuildingdoesnotmrrenllyhavcatcnanl.thatithmy NEW RESIDENTIAL MECH. SQ.FT OU
responsibility to notify the occupant of the requirement.which most be met
prior to ance ofa Certif ale fOmupanry. pQ
or auth agent Date /
ud r'
TOTAL: ISSUED BY.
OFFICE COPY
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FAX: (409) 53. W w iw 4 E v
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