21618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Projectldenlulratlon PERMIT NO.
Building Add�. t w000f+�Lk- e�augEl c,Q.T) . 21618
ane:
r. .mr. C CITY OF CUPERTINO-BUILDING DIVISION
Contrato2s Name: Lk.No: APPLICATION / PERMITLt3
I 1 ^ 0G BURDINGELECIWCALPI.UMBING-MEUlAr ICAL CATEGORY CONTROL.
AreLXM/En rce Uc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. s PERhTIS5lANIX
lher affirm,
LICENSED CONTRACTOR'S DECLARATION V
y ®
T
m,that dunder Provisions dChapler9(mvmc. APPLIANCES-RESIDENTIALIngwlth Srmiot700of Dbtslm3oftheeuslnesasand lmfodwsCnd,,and my
JOB DEECRITTION
Ilmnx is in fnfl17 and dftt. /ymay- p.� PANELS FQLI!TO 2DO n
w /
Llansc Che, Lie I �{ 7 QO 1 !
Dae Contntor
ARCHITECI-S DECLARATION 201-t000A.
q�q�uu WWWz ZZC Iunderstand my plans,.hall be uxd u public records. OVER1000AMTS SQ.FT.FLOOR AREA $/SQ.FT.
00
k tj Lkensed Professional SIGNSEIECRICA, Z23(� 0
GOWNER-BUILDER DECLARATIONUI
SPECIAL CIRCT FII.SCL-
Zi.., 6. Ilu,mbyaf�nn that I am exempt from tint,Contra or'a Lirese Law for the /
O�F following n .(SeMon 70115,Business and Profeauns Code:Any city or IFMPMETRORfOLEINST. 583 `Irilal
Fmuntywhk requbeaapemdltomrelml,alter,impmve,demolbh,mrepalr
q anyemutunpt tolte Wuance,aborequ4 theappbl ntforwchpe tto POWER DEVICES
6 O file a signed abstement that he is llmrued pursuant to the provbiaa of the
OF, Contnnora Liceme Law(Chapter 9(cammmndng with SeRbn 700 of DM- SWIMMING POOL M1CrRIC 3� VALUATION�5 eion3ofthe Business and ProfessbnsCode)ortha he b exempt thererromand
O s the Insb for the alleged exemption. Any violation of Section 7MLS by any
OUfI.EI55WIICF�SFDC1Uit6
appbontforapermltwb"theapp"nttoaddlptmhydnamontlun J Uy
c, flue hundred dollars($500).
�n
F1 1,as owner of the property,or my employee with wages as their rob NEW RESIDENTIAL ELECIIt 9QFT. STORIES TYPE CO UC N-
compensation,w0ldotheworkandtheemutunhrotineMedorofferedfor NALE 1
psale IS,,7044,Business aid Pmi®ion,Cade:The Cmmaaora LI¢nse Law
data ocapply toss awrer dpmpertywho bulldsly.,pvnlhermRandu6 OMP PP.. whr,memech wohhmntelf dedorngh hieownemp,however.the
hmutwch P
Impmvemrnhamnot Intended earofnd pl eale.If,however,thewibiogve TOTAL:
ImprovemeN bsokl whhln oneyearofconpltbratheowner-W Ilderwill have
t Men d proving slut he dm ow wild or improve for purpose ofule.). QTY, PLUMBING PERMIT FEE
Lj 4 as owner of the property,am excwtvely contracting with liomsed PERMIT ISSUANCE CAI NNE
contratws to mnstrut the pmje t(Sec 7004,Businessand Prdessba Code. WI��
The Contractors Lice.Law does not apply to an owner of Property who ALTER-DRARJ A VENT-WATER(FA)
Wilds or improve thereon and who comma. for such ptnjeN with a
r LJ I
gpadorW O¢osed w
purant to the Contndea
ts Llae Law. BACK FlAWPROIFL"f.DEVICE FEE SUMMARY
am exempt under Sec B A P C for Ihb renin
DRAINS FLO)R,RODE,AREA,NND. SANITARY Y_ N_
Owner Date RFCFFIPTT A
"ANWORonthat COMPENSATION DECLARATION FD(TURF_S PFR TRAP SCIIOOLTAK Y_ N_
❑[henby affirm that i have o losura to of consent to o y-iwn,ora RECEIPT I
3M0,1Acertifioieof Workers C«npewmonlreunnmoraoetlffed copy thereof(Sec. GAS F.A.SYSTEM-1 INC-4 OUTLETS, PARKFFR Y N
3900,Lab G
1 olky Y GAS EA.SYSTEM-OVER 4(EA) DING DI e
Co nor I— I) ftir F. BUILDING DI VISION FEES
eetlneacopy hhereby
ththe d. GREASE/INDUSIRLWASTEINTERCEPTOR PLANCHECKFEE
��CI.tXled copy h filed with the city Irepetbn division.
CERTIFICATE OF FSFAIPTION FROM WORKERS GRFA'SE TRAP PAID
COMPENSATION INSURANCE SEVPR-SANTTARY SPDRM EA 2()FT Date Recef t#
(rNa serllon need nor nd amplted tithe pemdt b(more M1undred dollen
(SI00)ol®3 WATER HEATECW/VENT/ELrCTR ENERGY FEE Y - N
)artily that tithe petarrvnaorthe work rarwnlrhlwpem,Itbiaded,
1 shall not employ any person in any manner so as to become wbJet to the WATER SYSTEM/TREATING
Workers Compensation Laws ofCalfonh. Dale PAID
Z Q NOTICEEW RESIDENTIAL PLMB. SOFT. DatC Recei t#
TO APPLICANT-.If,after nuking thisCcrtBble of Exemou
ption,y
should home wbkct to the Workers'Comper,ation provisions,of the Labor TOTAL:
F N Cad,,you rout fort hwbh comply witheuch provisions or this Fermat shill be QUILDING FEE
� > deemed coke
od.
ao CONSTRUCTION LENDING AGENCY 5EISMIC FEE F O
lhenbyafilELECTRIC FEE
Uhat then h a construction gagmq for the perfortry a
Z a naofthrw.,kfurwhkhthks rmath Loved eS,,3097,CMQ TOTAL e
O Lordere Name A T PLUMBING FEE
LL F Lordero Aadmae I '° QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢ rify thdl have read this application and rate Wov
t theabe informationQ
loco c.1,gree to cromply with all dtyand aNmy.rdinam and elate laws PERMIT NUANCE FEES PAID:
} a nlaingtowidingmnslmtim,andhembyautha mprea utiveofthI,
1"` Z Wytoenter upon theawvo-nrntbred Property rat Wpaalon purposes. ALTERORADDTOMECH.
_ M'e)agree to aur,W emNfy and keep harmless the Cityof Cu tlno Date Rttci t#
agebut W610tks,Ndgnxw,mrsaM expeve whkh may in any way roue MRHANDLINGUNIT(rOl0,0D0CFM) SUBTOTAL:
against said City U conaaryaue d the granting d this Permit.
\ } AIR HANDLING UNIT(OVER 10'"CEM) CONSTRUCTION TAX
Sigvtun of AppB I Date IXHAlJST FIOOD(W/OL)GO CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applIant flheup rti lding noMompntetoo hhandhhannthe HEATING UNIT(TO 107,000 BTU) Date Ret: t#
I kaltala defined!bythe Cupertino Municipal Cada Chapter 9.17,and the
lit❑ahh and Safety ems Session 75537p)7 HEATING UNIT(OVER 100,OW BTU) TOTAL:
WYeNNo
Ol the appBant or future wilding o pant use NulpmeN or cl v VFNRIATION FAN(SINGLE RESID) ISSIIFIaTf[TTRA TE
which emit havrdaus air contaminants a deBrcd by the Bay Ana At, _-��_-ff'���-
QualltyMaugement Diatrict7 BOILER-MMP(3EIPOR 100,000 BTU)
Y.
tha rmadNeh d�amteta13requlremanbunderChapter695o( BOILER-COMP(OVEt1W,o00B FED 141991
the California Health A Safety Code,S iooa75505,75533 and 25SM, 1
understand that iflhewlldingdoes not c rmrtlyhave atenant that It m my NEW RESIDENTIAL MECTL SQ.FT.
reporeibilaty &afytheouteofO therequlrerrcnb wM1icM1 must be met City of 6,AI";t1
prior to lawawe da Cetll{o�te.aofOcovparuy. �J
�
Owoeroraulr ho v Dlte
TOTAL: ISSUEDBY:
OFFICE COPY