21849 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: ` (� A n
kveJ'10 fv fJ�lF ZG184 V9
T)IMcar sm.— it.. A
g4/ %t1% CITY OF CUPERTINdBUILDING DIVISIONANN
Contractors Name: Ls.No: APPLICATION / PERMIT
u 0 6 BUrLDINGE,ECnUCAI.PLUMBING-MFLHAMCAL CATEGORY CONTROZ2-3
s ne l0
1 G� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: y �f • PERMIT ISSUANCE Vd
ICENSEDCONTBA OR' DECLA 1 N
T hereby affna that!am licensed under provisions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingweh in fon 7000)ofd efect. the Buelnesaandl'rofeselonaCode,andm
license is In full tied effect. PANELS
Limnss�9ClaM_�LLk.M 49g� � '
DM.Aff,__J�Contndor Ami!1 f�—
ARCHITEC'SDECLARATION -am,
��qq+++ O I undeatand my pbm ehaB he used u public rerords O ER IO��O���Q�A����M�tt�1'� SQ.FT.FLOOR AREA S/SQ.FT.
hi��j Licensed Pmfeseioml SI SEItj;HCIQ
(,<a OWNEReBUILDER DECLARATION E,pG QgqLAT/M�
ZL, (herebya(ftrmtWtla731.5,Bfromihed ossein License Lw forthe d W
pQ fail owingrecon.(Sedlon7 tto Busineaandr, 1p mCode:h, ci or
K F'q dvntywhlch requliesa permittomnstruct,alter,Mpmve,demoWh,orrepalr - �' ''METER ORPOLE INSf.
`'q 7
it-le
priarto its Issuance,also requlrestheappliant forsuch permit to
fele a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
Contractors License law(Chapter 9(commencing with Section 7000)of Divi-
30:J Sian 3 of the Business and Profreaimu VAWATION Code)orthat he is esempt therefrom and SWBdMING FOOL ELECTRIC
a.•77 the bash!ar she alleged exemption. Any ,violation of Section 70115 by any 3OVfLE.ISSW[.ICfiE4FT%711R6
appBantfora Pemdtmbje theapplkanttoadvllpemlty .o ofnmthan l CJV
fivehundred1,as owner of the pr. NEW RESIDENTIAL ELECTR SQI.7. STORIES TYPECONSTRL'CTION
�n ❑Las owner of the property,or my employm with wages r there mk
mmpen.70K will dathe war!;.and ion.Cde: is hnmintended oroffered for
HO O sok(Sec.ot apply
to a now and f property
Code:The Contractors Limme Law
rl fie$ 'cion a"asuch roan owner offproughhis on emorlmprwvidedes that
- OCC.GROUP RES.UNITS
0.0. whodceaeurh work himself arthraugh hieownemployees,provided that such
improvements are not Intended oraffered formula.If,however,thebuilding or TOTAL-)6.�
Improvement issold withinoneyearofcompletloMtheowner-bulklerwill have
:
burden of proving that he did not build or improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /Z
contractor,to mmlruct the project(Sec 7044,Business and Professions;Code: l
The Contactors License Law don not apply to an owner of property who ALTER-DI(AIN&VENT-WATER(EN
contractsd
builds or Improves thereon, and who contrafor such p(ojes with a
mytr dor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LII am exempt under Sec B k P C far thio reason BACK FLOW PROTECT.DEVICE
OwnerData DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT M
QI hereby affirm that I have a certiBate of consent to calf-Insure,or a 3 FDM`RSS_PER TRAP 6.00 S 1I1001,TAX RECEIPT a
cedifiateo(Workers'Compematianlmumnmmaadifiadcopythereof(Sec.
3800,Lab Cd GAS EA.SYS[EM-1 WCAOIITLLTS PARK FEE Y N
Paltry# REC=8
Cy GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEER
amPCertlOed copy is herebyfamished.the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
fCl('�d copy Is(fled with the city inspection division,�1"� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP (IAID ' ••f_�•iGi/ 6G Z
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20CIT. Date !� Reeei t# �3a L•('O
(Chis session needd W ncompleted lithe permit b torrent hundred dollars
(8100erifythat
J WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
(certify thatoin the person performance of the work sorwhkhthiopesubjclowed,
I shag not employ any person In any manner are n to become subject to the
Workers Compensation California.
tlanlawsofATER SYSTEM/TREATING
ornla. Date PAID 6a
O Z Applicant NEW RESIDENTIAL PLMB. SQ.I7. Date Remi I# ��•�
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Wmkna'Compemat Ica pmvBiom of the Labor TOTAL: (7•$.
N Code,you=at forthwith comply with such provisions arthb permit shall be
LU > deemed revoked. BUILDING FEE
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Iherebyafftrm lhattherebe construction lending agency for the perfarm TOTAL ELECTRIC FEE ---
ance of the work(or which thio perndt b Issued(Sec.30Y/,Civ.C.) •�
V O Tender's Name
PLUMBING FEE X0_00
LL 1= Lender's Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lcedifythatlhavereadthbappBationandmtethattheabo el farmrtlon
bcoront.i agreeto complywith all city and county ordinances and state laws I PERMITISSUANCE 00 FEES PAID:
>• LL relatingtobuildingmmtmdim,andhembyauthor ereprnenmtivnafthb
FZ cityto enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. (1� Dale ReCei t#
qrtoMvrjmd,.fIy.ndkamPh.rrnI the City of Cupertino PV ties,' dgnrn sand ezpenem rtuyInanywayacaue AIRFIANDONGUNIT(7010,000CFM) SUBTOTAL:ity roa of the grant his Prmit.
AIR HANDLING UNIT(OVEt 10,000CFM) CONSTRUCTION TAX
ppli t/C read., Date EKHAuBTHoOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS% IALSDISCLOSURE
Will the applicant or fuNmbulld� gocmpanbtoremhandleh.erdous HEATING UNIT(TO 100,ODO BTI!) Date Recel t#
materiA as defined by the Cupertino Municipal Code,Chapter9.17,and the
Health and Safety Cader NN. 25532(a)? HEATING UNIT(OVER IDO,000 BTW TOTAL: ,Z
❑Y. u No
Will theappliant or low.building occupant useequipment or devices VENTILATION PAN(SINGLE RESID) •� ISSUANCE DATE
which emit hazardous air contaMmnts as cieftend by the Bay Area Air P p R®
Quality Management District? BORER-COMP OHPOR 100,000 BTU) !'U
4Y. ❑No
havereadthehazaMousmalcrisis requirements underChapter6.95of B'DrLER-COMP(OVE2100,000BTU) ��Q
the California Health k Safety Cade,Sediam 75505,75533 and 25536.1 R 21991
and.t..d that lllhe d does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQX7..
Iitylon pant ofthe bemm
ents which must be et � �
'or to an a i atcof
ner or th nt ^ Date
TOTAL: ISSUED BY. B YLy
OFFICE COPY