21880 ..
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ert Identification PE hUTNO.
I101bd leg Address: �l O� 21880
o( 3 moo- � d LF �, `
APPLICA LION SURMI 1-1 A A
G��G�� tine CITY OF CUPGRTINO-EUILDINC DIVISION
IT
� cnntraanraN,.mllc: �a �j� //�yy� / Lic.No: APPLICATION / PERMIT �—�—
�N Wa`-'�v r�(.�C_.A!`.' �� BUILDING-E,ECTRICAL-PLUMBING-MECIIAMCAI. CAILCAAY CONIi;lll. ry
Architect/Englneer. LIB No: (g "�
'r;v it. "a t.:'�d„ "�' r'r i,iY TU1LDING'PERMITIINFO• . .
QTY ELECFRICPERMIT,,d ,!^FiEfi�a
Address: ( [A"PPILIANCESRESID1
2M7T ISSUANCE I (y(�
LICI!NSCD CONTRACTOR'S DECLARATION
I hereby.
l am licensed under pnevIslonsof Chapter9(commene NML JOB DESC4 'TION
ingwilh Section 7000M Division 3 ofthe BmlOessand Profes.lon.Cude,and my
Lliciceennsese Is i1 n sfujfY )Gnd 1:e1fcf.eNct. � PANELS � F
F-1
Date IFTEC7_A�e.tzCedbT,'- p1AQNAAMPS (2 Co
ARCIIII'be to DECLARATION — �
1q�±p/d lundentand my plane shall beusedapublic records. OVER 1000 AMTS SQ.Fr.FLOOR aArR�Ps S/FO.Fr.
SIGNS ELECTRICAL
2•bjl�j I,IcenscJ Professional
6 OWNER-BUILDER DECLARATION ^� J
fn In to SI'fC1ALCIRCU7� 1
L, 7 I hereby affirm that l am exempt from the Comractore Llceroe Law for the _ _ N
Z 0-�"s following reason.(Section 7!111.5,Business and Professions Code:Any Aly or
O µ9 TFMI'.ME'rrR OI I'OL•I S
K'a I.� countycture requimeapermittoconswct,aRer,lmpmve,demollsh, eelt I.
�,).a anyslmcture prlorto its lsmance also requires the appllcam for each permilto M p T
Y POWER DEVIC
�0� Elie a slrned talemem that he Is licensed pursuant to the prov(slons of the '
Contractors License law(Cha t r9(commencln with Section 7000)ofDivi- �y /J
F OQ skm3ofthc Businnsaod l'rofmioro Ccdd)orlhagxem
heiseptthemfromand SWIMMING POOL ELIC[ 6 % VALUATION
U J the basis for the alleged exemption. Any violation of Section 7WIS by anyUl1,ETSswil'CLIPS(ITixAi DR ..�..r
,J u`��,��,•
applicant fora permit subjects(he applicant ma civil penally of not more than �QD�(_LJ- C)d
fmIUi five hundred dollan(ASW). NEW RMIDENTIAL ELECIR SO.Fr. STORIES lYPECONSRUCHON
�j F11,as owner of the property,or my employees with wages as their sole -�
mmpereatim,will clothe work,andthestmcture beet lntendcdor offered for ' t) v�i
to(Sec.7(R4,Business and ro ProfesmoCode:The Contractors License hw
El docanmapplyto an nwnerrofproperty who Wlldsorlmprevea thereon,and OCC.CROUI' Ahs.UNIT
whO dorssu<h work hlmuil orlhragh hisown empboyees,provided that such
Improvements are not Intended oroffered forsale.If,however the building or TOTAL. 37s
improvement bsold within oncycarofeomplelion,the owner-bullderwlll have
Ike hu rden of proving that he did not build or Improve for purpose of sale). QTY. PLUMBING PERMIT FEE ITOOO ZONE APN
LI L as Owner of the property,am exclusively contracting with licensedcotr ( PEUdI'I ISSUANCE ^ /aIYrk
ondrad.to nsuct the project(Sec.7014,Bminess anns d ProfessigCode: L D
'The Contractor's License law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for surh ptokRa with a �� ALTER -WAIT3t(FA) 'Z cQ7
0. 11{aemrW)uan.ed pursuant to the Contractor.License Law. FEE SUMMARY'
LII am r.em(n under Sec. B & P C for this reason BA PROTECT.DEVICE.
Owner Date URNNSIlAO OOP,ARCA,COND. SANITARY Y_ N_
RECEIPTN
WORKMAN COMPENSATION DECLARATIONIIXTUAFS I'ER'I'RAP SCIIOOLI'AX Y_ N_
❑I hereby affirm that I have a artlflcate of consent to self-Inmrq ora I RECEIPT N
mrtlflrate Ol Workera'CompevaRonlmunna graartlfled ropy tM1emof(Sec. GAS PA.SYSTEM-11NC.40 .FIS PARKIa Y N
3800,lab C.) r� _
Policy M RECEIPT
GAS EA.SYSTENI.OVER 4 )
Cnm any BUILDING DIVISION PEGS
�cdrtuledropybherohymmIsnca. ctarnse/INDusnaLwA :I TOR PLANCFIECKFEE
�Cedlfled copy b filed with the city Inspection division.
CERTIFICATE OF 1"_MITION FROM WORKERS' )CRM11 PAI D'
COMPENSATION INSURANCE. RARY R1RM Date RCCCI� r�
CI'hlesnction need not W completed if the permit Is formic hundred dollars
(3100)x1 m.,.) T VFNT/ TR �y ENERGYFEE YNIcirtifythat lnthd perfmoianceofthdwmi,f.rwhlcM1 this permit is Issued, q1 shall not employ any person In any manner so a to become abject to theworkers Compensation laws of tiufornia. Dale n PAID
O Z Applicant ALP SQlT. Date Receipt#
Z O NO LICE TO APPLICANT:If,after making this Certificate of Exemption,you —
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Codr,you most forthwith comply with such provisions or this permit shall be
cc deemed revoked. ICFEE-E � _ Jy
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IhrrebyafflrmtlnttherebaconstructionlendingagengforthePerform- TOTAI: ELECTRIC FEE tXi
7 Z encculthc work for which this permit is Issued(Sec.3B97,CO.C.) l
60 cndrr'.No PLUMBING FEE I q (�
b. ' QTY. MECHANI CAPERMIT FEE
LL eedrrs Add.ess L MECHANICAL FEE
O W IcedifIthat lhaveread plythis with allcitlonand dcoutet that the above Information
brunet building comply with and hereby county Ord lnanmand etatelaws LPFXMRISSVANCE Zs CYC FEES PAID:
>. N cilatingmbulpon t roaWc,logandhereeportyor In rcpresenpurpos of this
Sb
Z cit(Wenter uponhe III,mentioned preperty harmless the
Cit purposes. ALTFROR ADD TO MECii. 1 Date Recei td
(n agi� tq ,In molly n d keep harmiev the Clty o(Cupertlno P
U ale. . abililes,' d dexpenses which may In any way seems AIR HANDLING UNIT(CO 10,000 CPM) SUBTOTAL:
a Is a it ns �n o cgAa.ling.1t1d.per/1 / AIR IIANDWNG UNIT(OVER IQ"CFM) CONSTRUCTIONTAX
Signa re of Applicant/Contractor y/ Date DCILAOS r 1Iom(W/DUCT) CONSTRUCTION TAX PAID:
IIA ZA R DOUS MATERIALS UI SCLOSU RE
\Willt applicant or future building Occupant store or handle haiardous FIFA'CING UMT(T0100,000 BTU) Z -C]} Date Receipt#
iaterialh dined by the Cupertino MunlclpalCWeChapter
llO Yesd Safety Cude,.S dirx. 532(a)7 I EATINGUM'r(OVER10Qo00B'1'IJ) TOTAL: s
No
Will the applicant or❑❑future building Occupant use Nulponent or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit ha'rardo.,air contaminants i s defined by the IL iy Area Air lL--
Q0ity hlaagc.nt District] BOILER.COMP DI B'OR 100,000 BI LB
4 Yes — PAJO
t have read the bazar a materials irqulmmenbunder Chapterii.95o1 BOILERCOMP(OVER 100,000BII)
the California Health&Suf&y Code,Sectlom 25505,25533and25534. I
understand that ifthe building does not currently havcaknanl,that It lsmy, NEW RESIDF.N'DAL MECii. S'Q.FI'. IIIa�� UlJy'
responsibilitytonit Ifytheoccupantoftherequi,er .tswhichmustbevrl 7'J
prior to Issuance of a Certificate of Occupancy.
(Tuner or authurl'rN agent DatcTOTAL. ISSIIHDIIY:_
OFFICE COPY �� ��