21937 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PLRMIT NO.
Yin�dm l L F 21937
ne / � A A A
CITY OF CUPERTIN0.6UILDING DIVISION Q
Corr r' N r LI
APPLICATION /PERMITAnk r�U�
o BULLDINGELECTRICALPLUMBING-MECIIAMCAL CATEGORY CONTROL p
Arc /Engines Lie.No:
QTY ELECTRIC PERMIT .�FEEEEa BUILDING PERMIT INFO
Ass: PERMITISSUANCE /.iJ' 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
Ihercb0ARCHInCT4SM'fLAKAfI6N'
Be, sed under provisions of Chapmr9(mmmarAPPLIANCESRFAIXNTIAL OB DFS "-1
IngwtihSsion3 ofthe Busimssand Professi Code,and my TJ/ � /ii�
license b I (M. PANES G !1 Ge/ ✓//'�j
License Cla Lit
DarER_� ntactor UPTOO2DOAM
✓✓ OVERIWOAMPS SQ.FT.FLOOR AREA $/SQ.Ff.
ureOu�pO I understand my phos shag be used u public records_
``j Licensed Professlowl SIGNSELECTRICAL
a E.t OWNER-BUILDER DECLARATION SPECLILCIRCUIT/M15C
f+ FTS Ihercbyafflrmthatlamexemptfrom the Contrac4or's Llrense law for the
77 0 ❑� following reason.(Section 7031.$Business and Professions Code:Any city or TEMP MEITR OR POLE INST.
�~ county which requires a permit toconstrocLalter,improve,demolbh,orrepalr
a anystm=mprlortoimbsuancgaborcqulreatheappUmntf rs hpermitto BOWER DEVICES
�e V Die a signed statement that he Is licensed pursuant to the provisions of the
�
s Contnttorb License Law(Chapter9(mrrorenMg with SMbn 7000)of Divi- gWrpslhgNG BOOL ELECTRIMC
M
n3ofthe Budnosand Profenlon Code)orthathebexempttherefmmand VAL4LjATIONE✓`-�
the baste for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWLTCHESFTXfURES ..�
appbant fora permit subjects theappllcani to a civil penaltyof not more than
p,ccc2Re five hundred dollars(5500).? NEW RESIDENTIAL ELFGTR❑1,a owner of the property,or my employees wages as their sole e'Q'hT' STOW ES TYPE CONSTRUCTION
Com
pensation,will do the work and the structure b not Intended or offered for
qsale(See.7044,Business and Professions Code:The Contractor's License Law
3� does not apply to an owner of property who builds or improves thermn,and OCC.GROUP RIS.UNITS
E who does such work himself orthmagh his own employees,provided that such
improvements arc not intended or offered for sale.If,howevep the build Ing or TOTAL:23 Lb
improvement issold withinoneycarofcompletbn,thowner-bu0derwlllhove
the Liu Nen of proving that he did not build or improve for purpose of ale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
M L as owner of the property,am exclusively contracting with Iimnse t PQt1,11T ISSUANCE
contractors to construct the project(Sec.7014,Busmen and Professions Code:
The Contractors License Law does no apply to an owner of property who
ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
builds or Improves thereon,and who coniracb (w such pRojecu with a
cq�[+ctar(s see rased pursuant to the Contractor's Llmnw Law. A W .TECJIDEVIC �_,
I_I I cep under Sec. B&P C for this re 'FLIIS
aeon DRAT �S.FLOORROOF,A' CO ND SANITARY Y_ N_
Op"IfData _ I RECEIPT p
WORKMAN COMPENSATION DECLARATION FLY PER TRAP✓ (' V SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a ceHBcate of consent to seifdnemof ora RECED'T p
Ivrtiflcate of orkm%Compevatlon Wurance ora arti(kd mpythemof(Sec. AS FA. SIID6-0INC.4 ARKFEE
3800,Lab
Policy a
Com any 4LEA.SYSTEM-0OVER ---- -- B UILDING DI VI sION FE Es
❑pCM10e m
is
a by (shed. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
py Is filed with the city Inspection division. I ��
CERTIFICATE OF EXEMPTION FROM WORKERS' CRF-ASE7RAP PAID _ (/
COMPENSATION INSURANCE SEWER-SANRARY-STORM G.200FT: Date RC 1#
(Thiess Han need notbe completed If the permit Ls forone hundred dollars
(5100)or len.) WATERHEATE W/VENT/ELECM ENERGY FEE Y_ N _
I ceHfythat to the performance of the work for which this permit Is Issued,
1 shall not employ3p/person In any manner no as to become subject to the WATER SYSTEM/TREATING
Workers Compe�{yrgsn Laws of California. Date PAID
O Z Applicanty/ NEWRESIDENTIALPLMB. 9Q.Ff. Date R mi t#
Z O NOIICE 'TO�I'PLICANT:If,after makingthb CMNoteof Exemption,you
should become subject to the Workers'Compensation provisions of the Labor T TAL:
N Code,you most forthwith comply with such provisions orthis permit shall be BUILDING FEE 1� x00
UJ ] dmmcd nwaked.CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 O
(L0 Ihercby of rnthat there leamrstroctlon houlogagency forth perform TOTAL: ELECTRIC FEE � no
7 Z anceoftheworkfor m this permit Is Issued(Sec.3097,Civ.C.) ELECTRIC EEE
(� O Lander'.Name _
LL ~ 1<nace,Add QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Orj W Imnl(v I have read thbapplic tionand statsthattheabove information
a Ismand rrect. agrce to complywlN allcitycounty ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. 0. to building construction,and herebyauthoriae repremntativesofthb
I'- Z chytoeroeruponth above-mentioned property for hopMion purposes. ALTERORADDTOMECH.
(We)agree to av demnlfy an d keep harmless the City of Cupertino Date Reec' t#
V ago inth hilities,' esndexpenseswh mayinanywayaccom AIR HANDLING UNIT(TO 10,000 CFM) SUBTO AL:
Z, sold c e ( n I.permit
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TA)
sign ofA mComr o ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TA Pnln:
HAZARD US MATER IALS DI SCLOSURE
Will the applicant orfuture build Ing occupant store or ha rad le harardous HEATING UNIT(TO 1 W,000 BTU) Date Re emt# lI-a"�'
matelot as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Cod a Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TO AL.
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hauNous air contandmnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OFR'OR 100,000 BTU) d��
4Yrs nn No "ate
have read the hucag.N materials requirements under Chapter 6.95 of BOILER-COMP(OVIR I KOM BTL)
the Glifernta Plmlth&SafetyCode,SeHoro 25505,25533 and 25536. I AM
understand that if the building don not rrently have atenant,that it is my NEWRESIDENTIALMECH. SQ.FT. r/
re19Q1
s 1611 nosily the occupant requirements which me met s7
coast b
p or a "fl co( Fancy.
9l6T7AA((
91�
nerorauh lid agent Date TOTAL: ISSUE p BY..
OFFICE COPY