21003 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PLRWT NO,
Building Address: 21003
'T 0 0/"\
o`Z S u. G 3
Owners ams. I III,one. - A
144 91ri? RRA CITY OF CUPERTINO-BUILDING DIVISION
c°/�/djr�M°r• / J Lk.Na: APPLICATION /PERMIT
990111. f/Ay A'Arll fJ/�dINC�• .17P/NS IBUILDING-ELECTRICALDLIIMBINC-MECIiAMCAl CATEGORY COMROLX
'qWArchitect/Engfncer, Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address! Y Q PEtMRTISSUANCE ❑ ❑ ❑
LICENSED CONTRACT 'S DECLARATION
I hereby affirm that l am licensed under provisions of Ch apter9(commene, APPEANCESRESIDENTIAL JOB DESCRBPI ION
ingwith Section7OW)ofDMv on3ofthe Bupnemand PmfemionsCode,andmy
nse isles fu v,(qt<x and MreM PANELS
Lken lass e) I
Lie.p
Date --JD— Contractor 12 10 200 AMPS
ARCHITECI•S DECLARATION 201-10M AMTS
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9
0 O I understand my plane shelf W used as public recce ia. OVER IBOB AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
F Licensed I'mfeasiatal SIGNSELECTRICAL
L 6 OWNER-BUILDER DECLARATION
In a SPECIAL CIRCUIT/
Zp, 1herebya((irm that l am exempt from the Contractor's License Law for the ftqc
qq following reason.(Section 7(1315,Business and Profession•Code:Any city or
Ff'q county which requlresa permit mcoeteart,alter,improve,demolish,orrepair TGMP.MEIFROR ]NST.
anystmMmpnortaibbauance,aLs mquimatheapplimntfwr chper tto
file a signed statement that he is licensed pursuant to the provision of the POWER DEV]
Ow Contracto/s Licarac Lew(Chapter9(mmmencingwlthSeMian7000)o(Divl-
�0� pon3o(the Bupnemand Prrdemiom Code)orthathebemmpttherefmmand SWIMMING //// ILI
/'� VALUATION
the Lasts for the alleged exemption. Any violation of Section 7ell.5by any OUTLETSSWhC XI'URFS I O ov-A
G
applicant for a permit subjects the a ppllcant to a civil penalty a na more then L t_J•�
five hundred dollars(5500). ft75ID ELI:CIR .
nI,as owner of the property,or my employees with wages as their sale SQFfSTORIES TYPECONSTRIKTION
t compensation,willdothe work and the•tructure is not intended or offered for
,J M a1e(Sec.7094,Bupnessand Professions Code:The Contractoe.License law
Id
y$ does nod apply to an owner of pmperty who builds or Improvesthem "and
OCC.GROUP RES.UNITS
0.0.
whodeva such work himself or through his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement baold wlthinoneyearo(compiMioMthe mvner-bullderwlllhave
tl( miconrpmving that he did not bund orlmprove for purposeafte, I QTY. LUMBING PERMIT FEE FTAOD ZONE MIN
use L as owner of the property,am exdu•ively contracting with licensed PERM ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAW&VENT-WATER(EA)
Wild.ar imp.therms, and who contracts far such pRojects with a
,➢.t clor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT. FEE SUMMARY
I_j I am exempt under Sec. B k P C for this reasonOUTSIDE ITS
Owner DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Date RECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
hereby affirm that I have o certiRate of consent m elf-insure,or RECEIPT X
M00,Late of Workers CompewHonlnurance oracenified copymemof(Sec. ' GAS EA SYSTEM4 INCA OUTLETS
Policyab CJ PARK PEE Y_ N—
Cr, apRECECAS EA.SYSTEM.OVER 4(PA) DING DTX
Y _ BUILDING DI VISION FRES
ertl0ed copy It hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Cenified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWERBANTTARY STORM EA.200pT. Date Rl t#
Rhbsection need not W complMed tithe permit b!Drone hundred dollars ae eceP
($10 ordify thworkat WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icenm matoyanyenorma anyh nnerfontobthbpe bjeit Rothearived, —
I stall not employ any person f any manner a u to become subject to the WATER SYSTEM/TREATING
Workcan Compensation Lawn o(Cali(omla.Date PAID
Q Z NOTIAppliE NEW RESIDENTIAL PLMB. SQ.Ff. Date Recel t#
Z O NOTICE TO APPLICAM:IL after making this Certlla/e o(Exemption,you
should become subject to the Workers''Compewtion provblonsof the LaWr TOTAL:
N Code,you mustfonhwith comply with such provisions or this permit shall be
� j deemed revoked. BU a
W 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE \
CL Ibeerbysflthat there bacoatmctiom n lending agency for the perform, ELECTRIC FEE
Z anceoftheworkforwhkhthb a rmitl•Issued(Sec.3W7,CIv.C.) TOTAL:
V O lender's Name PLUMBING FEE
U. I- Lender'sAddrem QTY. MECHANICAL PERMIT FEE
O W Icenlfythati have read thbappllcatlosand satethat the above information MECHANICAL FEE
fl bcmrmect.Iagreelo mmplywith all dtyand countyordlnances and pate laws PERMITISSUANCE FEES PAID:
} W relating tobuilding construction,and hereby authorize representatives ofmb
F Z city to enter upon the abovc�mentloned propertyforinpectlonpurposo, ALTER OR ADDTO MECH. Date R2Ce1 [#
V _ (We)agree m save,IndemNly an d keep harmless the City of Cupertino P
against liabilities,judgments,"sand expenses which may in anywayaceme AIR HANDLING UNIT(To 10,000CPM) SUBTOTAL:
against•sJq City in consequence of the granting of this permit.
tLs�J�� tg AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
'
.Slgig�(Sturree.1/Ap5ppflicnrit/Contractor Date IXHAUS'f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA]AR DOUS MATERIALS UI SCLOSURE
Will the applicant or future building Dau pant store or hand le hasardous HEATING UNIT(TO 100,000 BTU) Date ROCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I With and Safety C Ion 25532007 HEATING UNIT 100,000 BTU) TOTAL: \
❑Yea
CP
Willtheappliant tura building occupant use equipment or devices VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
which emit haxardo air contaminants as defined by the Bay Arca Air ���
QIlty Managemm Dlstn07 BDILFR-COMP DFIP OR 100,0(D BTU)
+q Yes °
have read the baza ous materials requirements under Chapter 6.95 of BOILFR.COMP(OVER 100,000 BTU)
the California Ilealth Safety Code,Section 25505,25533 and 25534. I sr:Pz a199Q
understand that if ullding docs not corrently haveatenant,that ltbmy NEN/RESIDENTIAL MECH. SQ.FT.
responsibility ton ]y the occupant of the requirements which must be met
prior to l-seance rtif Occupy ry. /�T�y1 /1ayD asu �
OW rorauthoriudagent Date JISSUEDBYYw1�jl�S����
TOTAL:
OFFICE COPY