21903 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
. Building Project Identification
Bn�Address E
8:1zo FAsf EsTATr s �R\ v
PERMIT N O.
21903
ner a i m: one:
RsaLElF ZS'3
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BNLDINGELECTRICALPLU.MBINGME LAICAL
APPUCA71ONSUBMTITAKE A
l
conaactnra Name: Lie. Nor
3 M I -t 5o 4%
CATEGORY
CONTROC�(^
C9 •'CV �
Architect/Engineer. Lic. Nee
QTY ELECTRICPERMIT FEE
BUILDING PERMIT IPLIMBNFO
tt}?�� ^ �/
Address: CE LCONTTW k� SAn(
t PERMITISSUANCE
MIll
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm'hat lam license under provisions rd Pro Cha
ssimea cls rul no-
Ing t...ISI han1ion 000Io(d Division 3a(the Budmssand ProfesslonsCode, and my
license lsln luB( ice and dfect. SoN
License 'n an 'Y
APPLIANCESRESIDENI'IAL
PANELS
JOtl DFSCILIPION
^a-�L
Date Contractor pLT!
10 200 AjrMS
M1.1000AMPS
ARCHITECTS CLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
s/sQ. Fr.
4,C1,2—
Licensed Professional
SIGNS ELECTRICAL
`l LI)
,C12OWNER-BUILDER
OWNER-BUILDERDECLARATION
I hereby affirm that I= exempt from the Contractors License Law for the
sI'ECIAL CIRCNT/MLSC
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Busnem and Professions Code: Any city or
county which requlreaa permlttoconstmq alter, improve, demoLLah, orrepalr
anystmoure priorto Its Issuance,alsorequimtheappllant forsuch permitto
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Dlvi-
sion3 of the Buvsineend Professions Code) or that he b sumps therefromand
the basis for the alleged exemption. Any violation of Section 70015 by any
applicant for a permit subjects the applicant to a civil penalty of not more W n
POWER DEVICES
gN'Ir1MING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES s�
VALUATION
G 00T4. Od
NEW RESIDENTIAL ELECTR `"O'er'
five hundred dollars (SS00).
❑Las owner of the property, or my employees wages as their sok
STORIES
lYl'ECONSIRIICTION
compemation,witl dothe work and thestructure la not intended or offend for
sae(Sec. Bu siness and Professions Code:The Llcenx law
does apply or impctofs
whodoessuch toanowner ofproperty
w workhlmse ughhiswho nem orits,pre thereon, and
hbownemp, rovidethat such
OCC. GROUP
RES. UNITS
provemuch
Intended however,
Improvements sonotintends oroofc Tomsk.If, however, deer ilI have
Improvement iswld wlthinoncyearofcomplHlon,theownerbuliderw111 have
TOTAL:
i Men of proving that he did not build or improve for purpose ofsak.).
Lj L as owner of the property, am exclusively contracting with license
contractors to mm44, truct the prayers (Sec. 70Business and Professions Code:
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FTADD ZANE
APN
The Cmdract.e. License Law does not apply to an owner of property who
Wilda or improves thereon, and who commets for such ptojects with a
LLLL1,0 Is) Bcenxd pursuant to the Contractors License Law.
15I am exempt under Sec. B lk P C for this mason
ALTER -DRAIN &VENT - WATER �)
BACK FLAW PROTECT. DEVICE
FEE SUMARY
M
OUTSI DE IT
Owner Date
DRAINS FLOOR ROOF, AREA, COND.
F0(M(ES PER TRAP
SANITARY Y— N
RECE Fr M
WORKMAN COMPENSATION DECLARATION
❑I ate m affirm that 1 have certificate of consent to rpytheroo (Sa
certificate of Worken'Compensatlonlnaurance ora certified ropythenrof(sec.
3800, lab C.)
Policy p wA I OB IQ ^'O U O ZQ
SCHOOLTAX Y N—
RECEIPT M
GAS EA. SYTrBM-1 iNc.4 OUTLETS
PARK FEE Y_ N
RFGEPr N
Com anv_� DLD KR O
GAS EA
EA. SYSTEM -OVER
B UIL DING DI VI SION FE ES
�CertNed copy is hereby furnished.
Certified copy b filed with the city iceespocdon division.
GREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECKE&�
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE se
(ThisctIdlon need not completed tithe permit la for one hundred dollars
(5100)orlyth
I ll set employ any arson i a n tmanner so as tobeco pcmNt b iso theexi
I shall not employ any person In any manner m ns to berorre subject to the
W plica'Compensatbn laws o/CaB(arnla. Date
Applicant
OTIC
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you
`��J{�pp
PAIDl E IjCcel (#
OtS
SEWER SANITARY STORM EA MOFT.
WATER HEATER w/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Recei til
WATER SYSTFM/TREATING
NEW RESIDENTIAL PLMB. sQF7.
should become subject to the Workers'Compon atton provisions of the Labor
Code, you most forthwith comply with such provisions orthls permit shall be
deemed revoked.
TOTAL:
BUILDING
LOO
TOTAL:
CONSTRUCTION LENDING AGENCY
lhercbyaffirmthat there is a construction lending agency for the perform
nce of the work for which this permit is Issued (Sec. 3097, Civ. C.)
lander. Name
Lenders Address
I ceitifythat i have rcadthisappliationand state that Neabove In(orrnatlon
brorna<. I agree to comply with all city and county ordinances and nate laws
misting to building comtmction, and hereby authorize representatives of this
city to enterupon the above-mentionsd property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, cost ...d exper. which may In any way amee
against said tyi nseque ofthe ni0g
toftFiapermit.
SEISMIC FEE
ELECTRIC FEE
L5-0
L 'I.0-
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE /2.60
ALTERORADDTOMECH.
AIR HANDLING UNIT(rO Ig000 CFM)
PLUMBING FEE
MECHANICAL FEE
FEE -PAID-
Date Receipt#
SUBTOTAL:
M
AIR HANDLING Ur(OVER 1o,000CFM)
CONSTRUCTION TAX
,{'�Fe
slgnaW fAppBant/Contratl" OrF�(iKa]jin_-
��
Date
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant in future building occupant store orhendle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
lkalth and Safety Code Section 75537(x)?
� Yea j] No
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATINCUMT(T0100,0001TTU)
Date Recef f#
_
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
t
Will the applicant or future building—pant use equipment or devices
which emitm haaarcioair coromithanb as defined by the Bay Area Air
Quality Management District?
Yes 9❑ No
have read lealth& Sa Jxl materials rcons 2555,2553 aChapter.1 of
' the Californla Iiealth & Safety Code, Sections 25505, 25533 and 75534. I
u ndenaand that if the building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occups nry.
VENTILATION PAN (SINGLE RESID)
1$ jj(da,DATE
I�-'�B
l
P 7X991
D
Mot now
G�s+av-'
ISSUED BY:_
BOILER -COMP DEEP` OR 100,000 BTU)
BOILGR-COMP(OVER 100,000 BTL)
NEW RESIDENTIAL MECIL SQ.FT
Owner or authonzed agent pate
�
'I'OTA L: L.L'Rl
OFFICE COPY