21624 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Project Identification - LOT
Z 5 P'r}UATNO.
Buildi"ideSZ wo�p res
VtA_t a_ IF N G �� 21624
Phone: APPLICATMIT9099T177E=
&V_gabo�zCQpuP T.sG CITY OF CUPERTINO.BUILDING DIVISION .� q�
Contndar.N'ria: n Ix.No: APPLICATION / PERMIT
/0 L{30O4 BUIIDING-ELECiRICALI'LI7hfBINGMFLHAIv`ICAL CATEGORY CONTROL 0
ArchBect/Fnglrieer. �}`
C —O 'S QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address I'FREATISSUANCE ki� . I PLUMB MECH
® 111
LICENS EDCONTRA nderp DECORATION
I hencct1en70W)olamllcr3of6 derpmvWmsofeadoer9(mmrr�mc APf4.IANCESRESIDEMiAL JOB DESCRIPTION
Ingwlth Io anJ7(v1�00a)afdrifiect. the Budrcsaand Pro/esdomCade,and my
Llm.Cllt.n 817 Ndl�kf:' �k3��7 P,Nms s FQ -
Date Cordractor UP 10200AMPS
ARCHITECPSDECLARATION 271-1 OOOh
µQ�QCO IuMeratnd my ptm.haB be,.Mn upubllc reoorda OVER1000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
F U Licensed Prvf®la.l SIGNS FT FIC7RICAL I q
OWNER-BUILDER DECLARATION S[+ECJALCD2CUI.I./MLSC L�11
5 Ihenbyafflrm that I am exempt from the Conaractoriicenc
Le Lw for the ( Lt
pp folbwing reason.6.tion MIS,Scale.and Proferobn.Code:Any dtyor
O 9- TEMP.METER OR POLE INST.
F� mrntywhlchrequl apem towwr Malter,Impmve,de=m hornpdr
q 6 anydmdunprbntoitbnuame,atorequh.theapph=ifmms pemdt[o POWER DEVICES
Li U file a dgeod datement that he It heisted pursuant to the provbloru of the
°3wG Contract.e.Llcv.Lw(Chapler9(mmmndngwlth Section 7000)of DIN- SWIMMING IDOL ELECTRIC
F�Oa dan3afthe Bu.inem.nd PmfcabmC: delorthatheboma ttherafmmeel VALUATION
•.t the bmb for the alleged exemptlm,. My violation of Section 70115 by any
fi °pPRcait fora PemJt.ubjed.the applicant toa civil peruky drat monthan OUTLETS-SWITCHES-FIXTURES
e five hundred dollars($500). 1 ✓ L
F-11,as owner of the property,or my employers with wag..their note NEVIRESIDENTIAL ELECIR "EA)
STORIES TYPEODNSIRUCTIDN
mmperuation,wBl do the work.and the structure is not intended or offered for
Orole bee 7004 .inea.a rd Profmlom Code:The Contnctea LIame,Lw
$ do.not apply to an owner of property who builds or impmnes thereon,and IN
j^ who dm such work himself ordrough hl.own employe.,p.1ded that suchcoo Eft RES.UMTS
Improvement an not Intended oroffered forsale.If,however,thebulMing. C
Improvement taoW whhln oneyearofcompletlon,the owner-0uRderwWTuve
tl�urden of pmWng that he did rot build or improve f.purpose ofnate.). QTY, PLUMBING PIJ I,ae owner of the property,am eschuNely ooantrxling with 11¢mM APPERMIT�l1ANCE
The Contractor'.Lkemu Lw does not apply to an own.of property who ALTEI[-DRAW 6 VFM-WA7FR
builds or Imprvsea Ihemon, and who contracts for wch p ped,with a
c nalfactarta sawed purnunt to the Centndor s License Lw. FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason BACK FLAW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT s
WORKMAN COMPENSATION DECLARATION pp(TUpFS I'pt TRAP SCHOOL TAX Y_ N_
F-11 hereby aHlrm that 1 have a certificate of consent to self-Wort,or a
certificate of Workeni Canperviatlon Iruunnce or a.rtlffed copy thereof(Sec. REEK T
3800,Lb CJ GAS EA.SYSTEM-1 WC10117LEfS PARK FEE Y_ N
I'd I
Comm RECETPTI
± v l h U C3 BUILDING DIVISION FEES
L lc:enlBed copy it hereby famished. GAS EA.GREASE/WDUSrRL WASTE IMERCEPTOR PLANCHECKFEE
!c`�T—TCedlfied copy t filed with the city Inspection dWldmt.
CERTIRCATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID '�'`
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA d7OF7 Date Recel [# .
(fhbeectbn need not be completed If the permit is/or one hundred dollars
(3100)orlesn3 ENERGY FEE YN
InNfythat In thePcrformanm ofthework forwhlch this pemdttlamed, WATER HFATERWfVN _T/ELECTR —
1.haB rat employ any peen In any manner m n to become wrbiec to the - '
WATER SYSIElA/7RFATINC
Workcrs'Compensatbn Lw.of GBfont.Date PAID '
O Z Applicant NEW RESTDINML PLMB. SQ.FT. Date -Repel t#
Z O NOTICE TO APPLICANT:lf,after making tht CertBkate of Fxempton,you
N should became abject to the Workers'Compensation proWdom of the Labor TOTAL:
cc Code,you must forthwith comply with wch petwisbm or this pertNt.hdl be
] deemed revoked. BUILDING FEE
CONSTRUCTION LENDWGAGENCY SEISMIC FEE Oa x
a hereby alfl rot utthemtacom mction herding agency for the pedorm
Z arm.fthevrorkforwhkhthh cox is lasred(Sec.3097,CW.C.) TOTAL: ELECTRIC FEE
Q,Qfl
0O Lender'.Name �r PLUMBING FEELL. e
F Lnder'.Addrmx QTY. MECHANICAL PERMIT FEE
O w to AifythatlluvenadtheappllotbnaMraatethetheabovelnformatim MECHANICAL FEE
tcorroot.Iagneetacvmplywithall cltyand couotyurdbunm and late lawn PERMIT ISSUANCE FEES PAID:
> N relatingtobulldlegemarudlon,•nd herebyauthenimmprernttN.oftht
I— Z dtyt.t,meruponthe abovrrrcntbned pmpertyfor Inspection purpos.. ALTFRORADDTOMECFL Date Recei [#
(We)agree to save,inderrrdly an d keep harmle a the City ofCarpertiro
V agaW WbiUtk,judgment,matar expem.whlchmaylnanywayac a AIRHANDLINGUNIT(I7010,000cE11) SUBTOTAL- _ or
ago Wiz_CNyNmn.equerce ofthe grantk,g a/tht PPP1°��'''���I"""B. AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
�'� � � L IN I t CONSTRUCTION TAX PAID:
Sigvturc of ApPBant/Cantracta �F�am EXIIAIJSf HOOD
HAZARDOUS MATERIALS DISCLOS RE1
Will the applicant or future building occupant atom or handle harandous HEA77NGUNTT(TO100,ODOYM) Date RC i t#
material as defined by the apertlro Municipal Code,Chapter 9.1 Z and the
Henan Pend Safety Code�Ia Mm
75S37p)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
gftl the applicant orf m building occupant use equipment or devtm VENTILATION FAN 61NCLE RESID) IV DATE
whkh emit"i-dws.ir contrtdnant,.defined by the Bay Area Ate
Q.rallty W eagromet District? BOILER-COMP DEE'OR 100,OOD BTU)
Yet, F�Na wdt 141991
4have read the h �w,
avrmearnryircment anti.Ghapter6.95 of BOILER-COMP(OVFR 100,001)BTU) htG
the CalBomle Health k Safety Code,Sections 75505,ri533 and 75530.1
undrntnd that if the building dm wt currently haveatenanL that it bmy NEW RMDENTAL MECH. SQ.FI'
rapomlbUity to notify the onvpant of the requirements which mast be net n[y nelnn ^'
Prior to loco of°Certi/icate.fO.Icancy. `1 M{�
win
Owns auth agent Ditto ISSUEDBY:
OTA
OFFICE COPY