21434 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO. YAj
Building Address:
,0 o - 21,43T
{
17 .dwmyib�ante: 9 6—/9yy A17
a
CITY OF CUPERTINO-BUILDING DIVISION
Contvctyor,1�Nam�e: � � � 9h�he L�//LLiic.No: APPLICATION / PERMIT
�JX�T/L/J� hi —7S 5 BUILDINGELECTMCAL-FLUMBINGMECHANICAL CATEGORY CONTROL
'Amhltect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adtlrca: Qll
ilas9 PERh9TISSUANCE F-1 1:1 ❑
LICENSED CONTRACTOR'S DECLA ION�97'�7tl
T hereby affirm that Is.licensed under provisions of Chapter9(commen APPLIANCES-RESIDENTIAL TOB DESCRIPTION
InenseISection forces ddiDiviedn3 afthe Buelnessand ProfeWon.Code,and my
LI.. le in fail(ane and effect. a, PANELS
.Class
Dale Contrador�J+a��. —UP TO 200AMPS
ARCHITECTS DECLARATION 301-IOW AMPS I fill
90Zp I understand my plane.lull be used as public records OVERI"AMPS SQ.FT.FLOOR AREA
FE d Licensed Prefeast ad SIGNS ELECTRICAL
<6 OWNBR-BUILDER DECLARATION
Ci SPECIAL CIRCUIT/M15C
7 X-, Ihercbyalflrm that]ant exempt from the Conlractor'e Lknnse Low for the
following reason.(Section 7071.5,Business and Profession.Code:Any city or
FE'c cauntywhkhrNuirnapermlttommtmdalter,impmve,de=o h,orrepair TEMP.MEIFR OR POLE INST.
.a anystm=mpAortolttwancc,abnrequimtheapphcant(or chpermltto
file a signed etatement that he la Bcen.ed pursuant to the provieiuns of the POWER DEVICES
g3µ Contcador's License Law(Chapter 9(mmmencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
SOS sior3ofthe Business and ProfessionsCode)orthat he la exemptthecetromand VALUATION
Q 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES or
applicant fora permit subjects the appIleart to a civil penalty of net room than
live hundred dollars($.700). NEW RESIDENTIAL ELECTR .FI.
L a owner of the property,or my employees with wages as their sole 75 TYPE CONSTRUCTION
C compensation,will do the work and the structure Is not intended or offered for
$ sale(Sec 7064,Business and Professions Code:The Contractors Llcerae Law
does not apply to an owner of property who builds or improves thereon,and QOCC.GROUP RCS.UNITS
who does such work himself or through hlsown employees,provided that such
Improvements are not intended oroffered forsale.It however,thebulldirgor TOTAL
improvement hold Mthinomyearofcompletion,theowner-b OderwBllave
tte�urdeo of proving that he did not build or improve for purpose ofsele.). QTY, PLUMBING PERMIT FEE FLOODIONE APN
LLj 1,a.owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
,00 contractors to construct the project(Sec.70K 70Business and Professions Code:
The Comrsctora License Law does not apply to an owner of property who ALTER-DRAIN kVENTWATER(PA)
builds or Improves thermt -
s, and who contracts for such ptojecwith• FEE SUMMARY
c9nuactor(O licensed pu r.uao to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B A P C for this reconis OUTSIDE FEES
Owner - DHe DRAINS FLOOR ROOF, GOND. ARY Y N—
Owner N
WORKMAN COMPENSATION DECLARATION ITXTURES PER TRAP LTAX Y N
hereby affirm that I have a certificate of concent to opythe sell-ingue,w a RECEIPT N
c iflcateofWorker%Compensatlonlnsurance oracertifkd ropythereo(XSec.
3800,Lab Cd GAS EA.SYSTEM-1 WC.I OUTLETS PARKFEE Y N
I'oliryN b S DD 3D O 3 RECEDING DIN
GAS EA.SYSTEM-0VER 4(EA)Com any BUILDING DIVISION FEES
Certified copy L,hercbyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CertlOed ropy is tiled with the city Inspection division.r CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFT Dale Recei lR
Crhbsectian need nest be complcted if the permit b for one hundred dollen D
($10(fimlese') - WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
I mrtifythat In the performance of the work forwhich this permit b Issued, Q
I shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB. FT. Date Recei tN
Z 0 NOTICE TO APPLICANT:Itafter making this Certificate of Exemption,you
Fshould become subject to the Workers'Compmeallon provisions ofth.Labor TOTAL
— Code,you must forthwith comply with such provisions orthls permit shall be BUILDING
W j deemed mocked.
CL G 1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-t D ELECTRIC FEE
7 ante of the work forwhlch this permit LuNOTA[.:
eo Issued 3097,Civ.C.) ((�
LL FLLL o a.r.Adde -erQTY. MECHANICAL PERMIT FEE PLUMBING PEE .O
O W 1certifythat I have nucithbapplicetionand rtatthatlheabove information MECHANICAL FEE
1 lamrrect.I agree to comply with all cityand county ordinaries and nate laws PE2MITISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representative.ofthis
city to enter upon the abovementioned property for inspection purposes. ALTERORADDTOMECH.? Date ReCel t#(We)agree to ave,indemnify an d keep harmless the City of Cupertino
V against liabilities,judgment,mob a cad eapenxs which may in any way... AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:
against said City in conxxgg cam of the grant Ing of this permit.
//gotZLpo Ilii /-5? -91 AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature o(Appllcan Contra r Date 7 EXHAUST 1I0013(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR DOLIS MATERIALS DISCLOSUR E
Will the applies cat or future build Ing occupant store or hand le hazardous HE3TWG UNIT(TO 100,ODO BTU) Date Recei 1p
.medal a defined by the Cupertino Municipal Code,Chapter 9.1Z and the -
I'fe❑aIthardSafelyCod loon 35534(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: (QQ
Wiilthea llcm r turebuildin cam antuxe i mentordeA., VENTILATION FAN(SINCLE RESID)
PP 8 P he P !SSU I ATE
which eMana ammo airDist
contaminants as defined by the Bay Arca Air ��'"r""{, �
Quality Management Dlst BOILER-COMP PIN OR I00,IXD BTU)
4Yro o Q
have radtheh ow materials requ Immems under Chapter 6.95 of BOILER-COMP 100,000 BTU) C��(pj Q
the C.Ilfornl.HeAth&Safety Code,Sections 35505,25533 and 35536. 1 9 b • -
understandthatifthebuildingdoes not amntly have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.IT. -
respansibilitytonetIfy the ocmpato of the mquimment which must be met me,
pua
rior Wi nccota Cemficaleofoccupancy. e.
• /��,sem /-9-9/
Owner or author dagen Date
TOTAL: ISSUED B
OFFICE COPY