21394 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT'PEN ONLY
Bulidin Pro en Idemifkalion - PERMIT NO.
Building Address: 21394
2066 I'
caner• acre: one:
v /SJ CITY OF CUPERTIN06BUILDING DIVISION ' I I J S
Contractors Nam: ' LIc.N. -- APPLICATION /PERMIT ' 7 CU
BUILDINGFELFCTRICALPLUMBING-MEGHAMCAL CATEGORY CONTROL#
Architect/Englneen Lk.No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
- Addrcec PERMITISSUANCE ❑ ❑ ❑
LIC ENS EDCONTR under rDECLARATION
I herebyaffirm70 shall ivisionsed 3 ofthe erpessand .session CDcle, nnenc- APPLIANCES-R75IDF.NTIAL JOB DESCREsfION
in ease l Section 700ce.rul eff e.n3ofthe Business and Profesel.n.Cale,and my '
Ikons isms force and effect. PANELS �,•�,I..e �.'�{� `�
Limnse Clan Lk.p //r7/s3 v` `•—
' Date_ ConhaRo1_4e s-•n.,sI� UP TO 200AHM
ARCHITECTS DECLARATION - 201-1000AMPS
q�+020 I understand myplausshxBbeused aspublicrecorda OVERIODOAMPS SQ.ET.FLOOR AREA $/a.Q.PT.
i4 b E Licensed Professional SIGNSELECTRICAL
<�6N OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
ZI'vU:}� Ihercby affirm that l am exempt from the Contractors License Law forthe _-
pO pMr
following reason.(Section 70315,Business and Professions Code:Anycity or
O Z F. TEMP.METER OR POLE INST. -
Py huntywhmpdrc ltes tss4aneatso �qui ttheapmvnifm lchprr oto
g any 4signerctaterloit that ace,licensed pursuant
plito
he t forsuc..of to POWER DEVICES
fila a eased statement that hat licensed punuant to the provlila) of the -
��5{Ou,I1�-.. Convectors uaires lad Proe tont Code)
with xSection
mptthenefof DWI-
.[on
WI VALUATION
aon3of the Buelnese end Pro(essl.ru Code)orthat he is exempt therafromand a��'wNC TOOL ELECTRIC
a..•,x]77 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWITCHESF7 FS _ "'1 �O O, A
appil"nlf.r.perma.ubjects the applicant to a civil penalty of.ot mom than 1 •7 V
O
five hundred dollars($500). IW DFMIA' ECTI6 pp STORIES TYPE CONSTRUCTION
z I,as owner of the property,or my employees with wages as their sole
Fa compensation,will do the work and the stmoree is not Intended or offered for
O
to(Sec.7064 Business and Prefousfow Code:The Contractor's License Law 4 n
does nor apply to an owner of property who Wilds or Improves thercon,and ` .'^ s ./..\ 17 OCC.GROUP RES.UNI'T'S
who doessuchworkMmselfarthrough hisoweemployaes,provided that such / „
improvementsarenot intendedoro(fered forsale.If,however,Nebulldingar s y
Improvement bsoldwithinoneyearofcosepletion,theawner-uta erwlll have -
tf�urdeoof proving that he did not Wild or Improve for purp o(ule.).� QTY, PL
LJ L as owner of the property,am exclusively mntraRing th Ikenes(1 PERMIT ISSUANCE
FLOOD ZONE APN
contractors to construct the Project(See 70K Busmen and Pro! Joie Code{ � qr,
TIu Contractors License Law does nes apply t.sn owner of p 4 who T06ARk31N& -WA
Wilds or Improv"thereon, and who con cut famyr
r such p(o' Iwith a -
qq➢IllLffact.rWhoomedpunuantto Me Contractor:1, rw .Law. FEE SUMMARY
c l sm exempt under Sec. B Nr P C to,th reason BAIX FLOW PROTECT.DEVICE -• F
e DRAINS FLOOR,ROOP AINA; ND. SANITARY Y N_
Owner . Date RECEIPT
La,
KMAN COMPENSATION DECLARATION PV('NRF_S I'ER N SCfI00L 7'A% Y N
I hereby,af(Irm that I have a certiRrate of consent to selNesure,or a - RECEE•T N
certificate of Worken'C.mperuatlonlneuranc ora certlfled ropy thereof(Sec. GAS EA SWEM-1 IN .IOVILEI5 PARK PEE YN
3800,Tab C.I
Pulley If /o�9Z'.a Z. _ - a RECEIPT
G EA.S -OVER CCCCgg�q��mpPPpa rt .�esL _ iJ//_ BUILDING DIVISION FEES
IFf Certified copy he hereby dwith the
city R E/MDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rL�l Certified copy V filed with the city IrepMl.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID -
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MOP Date Recei t#
Rhlssection need not be compicted lithe permit V lorore hundmd dollars
(g100)orlen.I - ENERGY FEE Y N
Icertlfylhat in the perfomurireo(thework(or which this permit is Weed, WATER HEATER W/VENT/ELECTR
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawsof California. Data PAID
O,Z Applicant NEWRESIDENTIAL PLMB, SQFT. Date Recei t#
Z 0 NOTICE TO APPLICANT:ILafter nuking this Certificate of Eermptlon,you
Fshould become subject to the W.flon Compensation pmvi.Wtuo(the Labor TOTAL: ,
N Cale,you moat forthwith comply with such provisions.,this permit shall be
Uj >' deemed revoked.' BUILDING FEF
a0CONSTRUCTION LENDING AGENCY - SEISMIC FEE t
I hereby affirm that there k a construction lending agsury for the perform- . TOTAL: ELECTRIC FEE
7 Z e.ce.(the work for which this permit is hound(Sec.3097,Civ.C.) "
00 lender.Name PLUMBING FEE '
LLI— 'Lender.Addnaa QTY. MECHANICAL PERMIT FEE MECIJANICALFEE•
O W
IsroIcertifythad have madthisapplication and statethattheaboveieformation
1 rrect.I dgree to comply with all city and county ordinances and state laws PERMTTLSSUANCE FEES PAID:
>- relating tobuilding c.nstruction,and herebyauthorize mpnesentativesofth6
2 city to enterupon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date REYeI f#
— (We)agree to save,IndemNharmless
ly an d keep the City of Cupertlno - P
ago Wt Babiatles,judgments,costa and expenses which may In any way accrue AIR HANDLING UNIT(Ip 10,000 CFM) SUBTOTAL:
agoext said City In consequence of the granting of this permit.
"`�/��✓ /"Z41R— AIA HANDLING UNIT(OVER IO,IXIOCI•TT) CONSTRUCTION TAX
Slgmture of App/llant/Contractor Date EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllca nt or future building occupant stare or ha nd le hazardous HEATING UNIT(TO I OQOOO BTT7)
materia l as defined by the Cupertino Mu metpal Code,Chapter 9.1 2,and the Date Recel t# .
I lexlth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
QYcs No
Will theappictut or alum building occupant use equipment or device.' VENTILATION FAN(SINGLE RESID)' ISSUANCE DATE'
which emit hazardous air contaminants.,defined by the Bay Arca Air -
Quality Mawgemenl DjsWctT BOILER-COMP OEN OR 100.000 BTU) a fla/
4 Y" IJ No
havereed Healthe h
a fol materials rcqu ections 25505,25533 aChapter6.95.1,o(, BOILER-COMP(OVER 100,000 BTU). t NOV
the
ersta dt Health building
Code,not
have a t nad,thiti1. f� V .t990
understand that if the bulldingdcea not arrcntly haveatananl,that ltbmy NEW RESIDENTIAL MECH. SQ.FT. UtJ J
responsibility to notify the occupant of the requlromets which moat be met
priorto Wuseceofa rtificate ofCkivpanry.
__.//.aril �•/'/I.f� ii/s/4u ���tY�N>f�Cn��•
Owner or awhoriwd agent Date ISSUED BI'L.J.J
TOTAL:
OFFICE COPY