21727 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ulldln f Pen oIdemlflc llon PMITNO.
Bonding ABddmas : Lor 3 u FR
.1 21727
era aces: one
A A
/L C) f//l CITY OF CUPERTINO-BUILDING DIVISION
Conuacto:aNanw, Lm.No: APPLICATION I PERMIT —
/ / CATTZORY CONTROL
A,chitet/Engineer: - LI,,No: eU1LDINGELECTR(CALPLUMBINGMECHANICAL
Slc/V L GO.vI ELECTRIC PERMIT FEE BUILDING PERMIT INFO
QTY
Add. PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IMmby a ffirmthatlamflc uduMerprovWomof Chaphr9(cummm APPLIANCES-RESIDENTIAL JOB DISCRB'ITON
tngwith Secdon70W)of Divlslon3ofthe Buslnessand ProfelsdonsCude,and my
license la In fuB f 2g d offect O p / PANELS
License Class �-
Date Contrador
ARCHITECTS DECLARATION N)1-100 "PS
NZ lundo.tandmyphrosMllbeuxdaspubllc.e a. OVERI"AMI5 SQ.Fr.FLOOR AREA S/SQ.FT.
q@ O
z Licensed Professional SIGNSELFGTRICAL /
6 OWNER-BUILDER DECLARATION SPECIALCIRCUT/MISC
L., ] Iherebyaffirmthat l am exempt from the Contractor's License Law for the -
Z O.. following reason.5etlon 7031.5,Business and Professions Code:Any city or
OZI.. TEMP.METTR OR POLE INST.
C`'�Ty O' county which requpriorrequires pauaAtomrotrouiresth applicant for
to
Q any structure prior to Its Lhat he is oho requires to the for such permit to
file a signed aatesen,that M h licensed pursuant m the provisions of the ]OWER DEVICES
Contradorl License law 3 (Cha er 9(mmmeci
nn with Section 7D00 of Dlvl-
res 8 w' ) SWIMMING IDOL FI.ECITIIC
110n3 ofthe Business and Professlom Code)cribs,he is exem thertfromand VALUATION
p the basis for the alleged exemption. Any violation of Sion 70315 by anyOVILETSSWITCHFSFTX URES
;FJi' QQ applicant fora permit subjects n the applicant to a eivll penalty of not mothan /
d, P' five hundred dollars(SSM. NEW RESIDENTIAL ELECTR
? � ,y,I,as owner of the pmperor my employees with wages as their sole SQ'T' STORIES TYPE CONSTRICTION
compose tion,will dothe work and thestmoun h not Intended or offered for
TF,O sale pec.7f K Busineas and Prolessioro Code:The Contractors License Law
('j, $ docs not apply to an owner of property who builds or improves therms,and -
=s" who don such work hlmselfor through his own employees,provided that such OCC.GROUP RES.UNITS
impmvementsamno intendedorofferedformle.ILhowever,thebuildingor TOTAL:
improvement hsold withinoneyearofcamplebmthe caner-b WerwBl have
to,,*rden of proving that hedld not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
LJ L a owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
cvntrecton no mrutruct the project(Sec.70K Business and Professbss Code: PERMIT ISSUANCE
Tia Contractor's License Law does nor apply to an owner of property who ALTER-DRAIN k VENT WATER(EA)
Wilds or improves thereon, and who contrafor such ptotic a with a FEE SUMMARY
�ttrractor exempt
order Sntmthe Cgntrators Llanse Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C (or this n
sect DRAINS.FLOOR ROOF,AREA,MND. SAMTARY Y N
Owner Date RECEIPT N
WORKMAN COMPUISATION DECLARATIONFD(TURE
bySCIi00L TA% Y N
❑I hereby affirm that 1 have a certificate of consent to self-lnsun,,ora RPER — NN
certificate ofWorlcrs Compensation Insurance ora certified copy (Se
py the.fc.
3800,1.bC.) GAS EA.SYSTEM-1 INCA OIJILFI'S PARK FTS Y N
IAillry N GAS EA.SYSTEM-OVER l(EA) RCCI]I'I'N
Com env ll.,�.<4O qct FrL BUILDING DIVISION FIFES
�Certlfied copy is henbyflished' GREASC/INDUSII2L WASEINTERCEPTOR PLANCHECKFEE
Certified copy h filed with the city inspection division.
CERTII'ICATB OF IAEMPTION FROM WORKERS' CRFA-SETRAP PAID
COMPENSATION INSURANCE
(Thiosetlonneed er.Mc.rn cpermuhfor one hundred dollenSEWER.SANITARY-STORM E.A.2(K)FT. Dabc Remipt
(510 mrifyth WATER I IFATIRW/VENT'/FZECTR ENERCYFEE Y N
Ialloy that in the person nceofthework so a tobocpermitctIs bused,
1 shall not employ any pawn In any manner so ss to become subject to the WATER SYSIFM/TREATING
Workers'CompenssBon laws of Glifomh.Date PAID
-
z= N'OUCApplIcest NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICETOvaubjetiothe Rcr nt'Con. CertBlaneof Exemption,you
skald became mbF t Io the Workers'Compevauon provuioro o(the Labor TOTAL:
~ N Code,you must forthwith comply with such provisions orthh permit shall W > deems revokd. PY P BUILDING FEE O
d CONSTRUCTION LENDING AGENCY SEISMIC,rEE
I hereby alfirm thatthem h a mnstrudlon lending agency for the perform ELECTRIC FEE
Z Anaofthe vo,Mrwhich thiopored, ed(Sec.309'/,Civ.Q TOTAL: Q
LL O lenders Name PLUMBING PLUMBING FEE
LL F 1<nder,Addmaa / / era QTY. MECHANICAL PERMIT FEE MECHANICALFEE A
O W d,iecttythatl to
Apply io with
state<hattbeabove information
a hmrngt building condmctl n,alndty ebyauhoruze npnasand Gate taws PERMIT ISSUANCE FEE PAI : 'I
} relating to building mtutrotlon,and Mnby authorize mpnsenhtives ofthh 2 (Q'15G
(•.. Z city to enter upon the above-mentioned property for Wpection purposes. ALTERORADDTOMECH.
V
against ll bgrr a to save,
a mode,cop and eskeep harmless the City of Cu peatino ate Receipt#
jug pensee which may In any way aroe AIR HANDLING UNIT(TO 10,=CFM) SUBTOTAL:
against said Cityy wquence of the granting of this permit.
L NR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX 3 —�
Signature of nppB cgn`rac, Date EXIMUS r uooD(w/DUC1) (�O ST UCTION TAX PAID:
l HA7 RDOUSMATERIALSI SCLOSURE
Iy -aL _�4s6
Will tM1c appllcwt or future building omsps store or handle hazardous IifATINGUMT(N100,000BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the p
Ilalth and Safety CWP SetlonliS537(a)7 HEATINGUNIT(OVERl W,000BTU TOTAL: djs O
❑ Yea N No
Willnheappllant orfutum Wildingoccupan,useequipmentordevims VENITLATION FAN(SINGLE RESID) ISSUANCE DATE.
which eodt hazardous air mntamtuanta as defined by ted Bay Area Air
(jaality Management District? BOILER-COMP(311P OR IW,ON BTU
4Ycs ❑❑Ng A
haverndthe th&S fet Code,Se rcons M5ntsund and 25534. 1 of BOILER-COMP(OV[R 100,000BN)
the Gltand hat if tth he building
Cods,Mt1om 25505,A533 tenant
that it 1 1991
nedpmtla ihtyI.f notify
the
don ofnot herequin,have atevhL ustithmy NEW RESIDENTIAL MECH. SQ.FT. FEB 4
napgtsibility to notify the ocevpant o/the mquimments which lust M trot
prior to once WaCetlfic tc lOmspanry. p �
•
/2--—/pG/ � `° stn. assn .,
Avner or out lull agent Date ISSUED BY:�•
TOTAL: —
OFFICE COPY