21634 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: - 21634
09'00 ;o E N'�w e
ante: A A
. Tal CITY OF CUPERTINO-BUILDING DIVISION
conlra�cnnr��sdame: LIc.N APPLICATION If PERMIT
,,>^A7 ��g�-+s Z `{ya a_ BUILDING-MECTRICAI nL BINGMFL LAICAL CATEGORY CONTROL
• Architect/En� Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE s' El El El
CONTRACTOR'S DECLARATION
Ihereectionr70 Qatlatm Bcen3oftheerprovlalonsof Cssions9de,and c APPLIANCES-RESIDENTIAL J DESCRIPTION
ingwhh Loftin fore and dslon3ofthc Buelnsssand Pro(esNonsCode,and my
license b In full force and died. PANELS
Class
License LicIf N
Date ContractorUP TO 200ANMS
ARCHITECTS DECLARATION 201-IOOOAMPS
o]_ I understand my plea shall W used as public records. OVER 1000 AMPS SQ.FT.MOOR AREA $/SQ.FT.
O
d4d u Licensed Professional SIGNS ELECTRICAL/
6 OWNER-BUILDER DECLARATION
Law for the
I„ / Ihercbyaffinnthatlatm exemptfromthe Cnmrador's License SPFGLILCIRCUIT/MLSC�
O Z following reason.(Sedlun 703L5,Bovines.and Profession.Code:Any dty or TEMP,METER OR POLE ST. ( \ /
ceuntywhich requtrssa permit reconstruct,alter,improve,densolb6,ormpair
q eery..l anystructure pdorto its Issuance,also requlreathe applicant for such permit to POWER DEVICES
pE� F S File a signed statement that he is licensed pursuant to the provisions of the
03i''rn Contractors License law(Cha Enter 9(rommendng with Section 70W)of Divi- SWIMMING;
L ECITtI VALUATION
O sion3otfo the
Professions Any violation f exempt therefrom and
the bean for the alleged exemption. Any t violation of Section not no by any
5' <X OUTLEISSWIICIiESFlXTURFS
applicant for a permit subjects the applicant to a civil Penalty door more than
O five hundred dollars(S500). NEW RESIDENTIAL ELECTR SQFT. STORIES 7YI'E CONSTRUCTION
❑I,as owner ll of property,or my employees with wages as thele sole
C7¢ compensation,Business
and rk.andthe srude;Th not intended proffered for VN 1'ZOV�� Npv 1
y�p sale(Sec.7064 Business and Pro(esalon+Code:The Contractors License Law -
�$� does not apply to an owner of property who Wilds or Improves thereon,and Pi1�A/-C47- OCC.GROUP RFS.UNITS
who doessurh work hlnaelf orthrough Ms own employees,provided that such
Improvements am not Intended oroffered for sale.If,however,thebuliding or
improvement bsold whMnoneyearofoompietlon,the owner-budderwlll have
the4arden of proving that he did non Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODLONE APN
E L as owner of the property,am exclusively contracting with Ilmnsed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractors Llcome Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or improves thereon, and who contracts for such pi,ojects with a FEE SUMMARY
cgnlpdor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJI am exempt under Sec. B A P C for this reasonQUTSIQF
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y_ N—�
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
❑i hereby affirm[hal I have a cediRcate of conxnt to sol/-insure,ora pIX.p(TpFry PER TRAP SCITOOL TAK Y_ NRECEIPT N
certlticate ofWorkers'CompewHon Insurance or a certlfbd copythereof(Sec. GAS FA.SYSTEM-1 WCAOU'ILEIS PARK FEE Y N
3800,lab C.)
I —
ollry AECEIPCN N
Co GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION ITES
any
CeniOed copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertlled copy Is filed with the city Inspedlon division.
CERTIFICATE OFUEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER-gAND.ARY-bTORM FA 200£1' Date Reeei tN
(I'hlasection need out W completed if the permit b for one hundred dollars
($100)orlm.) WATER HEATER W/VENT/p,ECTR ENERGYFEE Y_ N_
I cortify that in the performance of the work forwhlch this permit Is Issued,
1 shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workerd Compensationlawsof Californb. Date PAID
OZ Applicant NEW RES DENT ALPLMB. SQ.FT. Date Recei til
Z O NOTICE TO APPLICANT.If,after molding this Certificate of Esemption,you
should become.ubjed to the Workers'Compe.atioo provisions of the L.Wr TOTAL:
I- rn Code,you must forthwith comply with such provisions orthIs permit shall be
BUILDING FEE
LU j deemed revoked.
W
— CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
nZ aom.fthc workforwhlch this permit is Issued(Sec.3097,Cie.C.)
V PLUMBING FEE
LL 1- I.endcr'a Address QTY.O Miler'.Name
MECHANICAL PERMIT FEE MECHANICAL FEE
W Icertifythat l have read thisappllntlonand state thatthe above information
O
1 iscomact.l dgrce to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
f.. Z city to enter upon the above-mentioned property for inapectlon purposes. ALTERORADDTOMECH.
_ Date Recei tit
k
gree to save,Indemnify an d keep harmica the City of CupertNo AIRIiANUUNGUMT IT010,000CFM) SUBTOTAL:
billtln,' gmenIscosteandexpensewhichmayInanywayaccrueId Cit con.+syBLe eoltM cat ingdthbpermit. AIRHANDUNGUNR(OVER 10,000CIM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
o Appilcant/Contractor Date IXFIAI75'T HOOD(W/DUCT)HAZARDOUS MATERIALS DISCLOSURE
e applicant orfuture building occupant store or handle hazardous HEATTNGUMT(TO100,000BM Dates defined by the Cupertino MuNdpal Cod,Chapter 9.12 and the - —
I lcalth and Maly Coder.-S�ection 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOT
F-1u Yes No
Wiiltheappllcant ormtureWileingescupantusecqulpment ordevim VENTILATION PAN(SINGLE RFSID) LISSUAN GE DATE
which emit hanolous air contaminants as defined by the Bay Area Air
Quality Maragemenr District? BOILER-COMP(3HPOR 100,000 BTU)
4Yee F-1 No ®Cr 1
havc California theHealth
h &Sittety C de,is rcoW 25505,25533 and 255 r 6.95 of BO LER-COMP(OVER 100,000 BTU) 1992
the understand
t Health k building
Code, of tionscurrently
ntly have
a to nett,that I Ja7G
understand that If the Wilding docs not arrcntly haveatenanL that ltIsmy NEW RESIDENTIAL MECH. SQ.IT.
rapomibllity,to rally the occupant of the requirements which mustW and CITY UP CUF'enur
prior to issuance of a Certificate of Occupancy,
Owner or aulhorimd agent Date ISSUEDB .
TOTAL:
OFFICE COPY