21731 . APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProM identification v\ 04t PERMIT NO.
Bu
ilding Addraa: 21731
' 1 -2-r, Ctic1
am
Gr, G io'o S CITY OF CUPERTINO-BUILDING DIVISION ,
ContradwaName: ((77 Lk.Na APPLICATION I PERMIT
TJ�4'?aOG4"� BUILDINGELECiID PLUMBINGMkT'IIANI CATEGORY CONTROL#
Anhtt /Engineer. Lk.No:
kip a`"~t� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION u LJ =1
I hereby affirm that l am llcmxa under provisions of Cbupter 9(manman iDBD N
ingwith Se n7000)of Dlvldm3ofthe BudneaandProlesaimsCaae,cod
Lsce.flom te. r'� and d o P M P R ` F O W
Llmrwe Class `� LIC/ y-"�60 G '�-
Date Comrador
ARCHITECT'S DECLARATION 1-1000AMP5
02. I understand my plans shall be used as public recvda OVER] SQ.FT.FLOOR AREA S/SQ.FT.
{�yy O I
`� Liremed Professional SIGNSELRLMCAL
OWNER-BUILDER DECLARATION �P
'I., 3 Iherebyafgrmthetlamexemsptfromthe CorLLnstor'3 License raw farthe 9sECL1LCBiCI11T/M15C
p foBowing rtasm.0kam70315,Budne�and Pmfobra Code:Mydtyor
O y Fpq TEMP.METER OR POLE INST.
r"��� countywhidnrequlrnapemdtbmrowd,iltm,lmprove,demoLLsh.arrtpalr
S anyetmciure prior to lb fesurrce,aLw mryEesthe appBant for ouch pemdt to POWERDEVICFS
& a Ne a signed statement that he Is Boemed pursuant to the proWlnm of the '
W6 533 ww Cced—ols Lkeme Law i0haplrr 9(commencing with Setlbn 7000)&MA-
F O� s13ofthe Busleesa and Profembro Cade)orthat he b exempt therefromand SWB'U'UNC POOL ELECTRIC
onVALUATION
S the basis for the alleged exemption. Any violation of Section 70315 by any
OSS applicant for a permit objects the applicant to a civil perulty of nor rose than 0[mtiISMYHCF@SFIXURFS
M hundredadlars(5500).
1,u owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPECONSTRUCTION
compenselm,wllldothew�rk,mdthcilmdurt Griot Wended or offeredfor
r 0 sak(SeC706q Bualrosand I`mfeubm Code:The C.mradols IAce.law
SS who# apchy rk o Inmrfp w&h whowb ilemploylmgprpovwesthed that,anhd
OCCCROUP RES UNITS
Improvements ate not Intended mothered fosc.If,however,the building
or TOTAL
Mprovemeu hsaldwkhln orcyesrofcompldbn,thewmer-W Ilderwiro have
t rdenofprovingthathedid rwtbuBdorimproseforpurposeofsale.). QTY, PLUMBING PERMIT FEE
L sa owner of the Property,am ex<halvely contracting wall,Limoa d FLOOD ZONE APN
tontractan to corotrod the project(Sec.7014,Busher and Prdewbro Code: PFRMIT15SUANCE
The Contndorb Lloem,Law don not apply to an owner of property who
Wilda or Imposes th. , and who contacts for such p,jeN with a ALII]t-O]UAI4 VENT-WATER( -
-W7Tado0)licensed purwmt to the Contradar's Lle mse Law. FEE SUMMARY
L_j I am exempt order Sm B k P C for this rt BACK FLAW PROTECT.DEVICE OUTSIDE FEES
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
RECEIPT 4
WORKMAN COMPENSATION DECLARATION FIXTURM_PER TRA SQi00L TAX Y_ N
❑1 hereby af(Imt the I have s certificated avnsnt to self-Awa,or a
eedlfloa o(Worken'Comperoatlm Amu Moe e•aedHkd copy thereof$ee. RECEIPT
3800,Lab CJ GAS EA.SYSTPAf-11NC40I17LE15 PARK FEE Y_ N
C. # GAS EA.SYSIIM-OVER4(EA) DING DIVISION
Com nv 1 Is hereby
pCJ FGs. BUILDING DI VISION FEES
[Certified copy h heel withmthed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
®CedNed copy b Ned with the city Iropecibn division. -
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE Reoel t#
SEWER.SANITARYSTORM EA d]OFt' Date
(ITiaaMbn need rad b completed H the SURAL h(axone hundred dollaa
a100)ofeth) WATER HEATER W/VENT/ELICTR ENERGYFEE Y N
IeedHy the tsthe pedorsaneeof the work forwhlch wspermRis farts.#,
I atoll not employ any person In any manner o as to become subject to the
WATER SYSIFM/TREATING
Woken Compensation law.o/GII(omh.Dale PAID
NOTICE
Date Recd tX
Z 2 Nouldb ca esubjeANthe after maHom a ati nlabdonempbn,you
NEW RESIDENTIAL IaLMB. SOF[.
ahold become abject to the Worten'Compensation provbbm of the Lbor TOTAL
CC N Code,you must fort hwlth comply with such provislans or this permit dull be I QI 0
lin > deemed revoked.
eem
0 CONSTRUCTION LENDING AGENCY S I MI FEE 1253
aZ hereby alOmhe hnbacoumdlm kMingageny(orthepMom+ TOTAL: ELECTRIC FEE
7 anreoftheworkforwhiehthba tb baued(S-130 Y/,Civ.C)
00 Lender's Nacre l sl l PLUMBING FEE V 6,59
LL f Landers Address I`"I-I- QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 duythe l have read thlsappikatbnand sate that theabove Information
bcorrsa.Iagreetorm,plywltnalidtyandmuntyordlmnmsandstateUwa PERMIT ISSUANCE FEES PAID:
T 1 relalingmbuildingcomtrudlm, "hembymthoriznmpresentstivesoftMs
U) cilymoenter upon the above-mentbmd property for inspeelon purpose. ALTER OR ADDIO MWH. Date Reeei tq
V _ (We)agree to save,indemnify an d keep harmless the City of Cupedlno
against llnbWtiea,jedgmeds,cats and experaes which may In any way acvue AIR HANIXING UNIT CTO 10,000 CFM) SUBTOTAL'
aga I=sad City In consequence of the granting of this permit.
C � � T, AIR HANDUNc UNIT tovFR to,000CFM) CONSTRUCTION TAX
Sigmmm of rap ant/Cmtndo Aa 1 D,t EXHAUST HWD(WI DDrn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies utorfuture buBdag occupant store or hind le hazardous HEATING UNIT(TO 100,000 BT ) Dale RCYCI Iq
materai as dell red by the Cu pertiro Municipal Cade,Chapter 9.1 7,and the
Health and Salety Code Seam 25537(a)7 HEATING UNIT(OVER 1010,000 B'ru) TOTAL:
Yes �No
W the applicant mfumm building oovpant use equipment or dnvkes VENTILATION FAN(SINGLE RESID) ISS ATE
which emit hazardous air mnambunta as droned by the Bay Ana Ab
QualityF-1e,mgcrrem QN. BOBFR-C(1MPOFEOR100,0(OBTU) rEd 141991
4haYvereadtheharar ..materiabrtqulrtmentunderChapierG95of BOII.ER-OOMP(OVER iW,000BTU)
the erMa soh Health A Safety Code,ocK tum 25505,have
a t and 25534. I
underste allyl lithe tithe ingdoes rotmrrquire enta hith mustb mar, NEW RESIDENTIAL MECH. SQFT /s3ae. �IMts �y 1'
r®pomb0lty to natty the«cvpuLL d the m7uUcments whbh crust be rrct
prbrtolMuam:eofa�CsertlfketeofOmrpamy. `
O.vner or t agentI Dat ISSUE
TOTAL:
OFFICE COPY