21738 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin,Project ldemlflxativa 7LAY ! U0 PFRWT NO.
Badding Aaar,.,S S [�� �l p • ` 4 e, �_� 21738
�`f-vt til S?(t.xnv5 YgQkw AY
ane. ane: APPUCA UON qUBMUTAL
CITY OF CUPERTINO-BUILDINC DIVISION _
• e t «. me: q Ntt APPLICATION / PERMIT
BIRLIRNC-ME RICALPLUMBINC-UM AMCAL CAT`EGDRY CONTROL
Ll/C Oq/ �y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreati RMS
PFAhRTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l sm licensed under provisions of Chapter 9(mmUrmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth SooWn7000)of DIvINm3 ofthe Busfwsand Code,andrny
and
Lome b In fail�and,$c.# X�/Tq 7 , PANELSLio / (�
Date Chas{ ___Cont (.(� C� G L W
Dae Contndor
ARCHITECTS DECLARATION 10DOAMPS
W I.od.rd my phmahallbeueed aspubReremds. OVERI000AMPS SQ.FT.FLOOR AREA S/SQ.od F(.
OC ��
`j Liceraed Professional SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M1SC
Thereby affirm that!en exempt from the Comratlor's Lkenee Law fm the
]. 'q� following reason.(Section 70115,Busing and Professions Cadr.My city or
I—M5g cvuntywhkhrequlrnapem toww d,alter,Mprove,drm h,wrepr TFMP'METEROR POLE INS(.
`'YYS 7 any atruRurt tahemeWberarcgalnusedi puthemtothe forwlum of to
K �
file•Ngned statement that M b Bcen.ed pursuant to the proWsbro of the POWER DEVICES
O u,II-- Ce efts Llcrnse Law(Chapler9(mmmenengwith Sectxa.M)of Divb
30:1 =ofthe Businw and Prolesbe Cordal orNa halo exempt thenfromard SWIMh9NGIWLEILCIRIC VALUATION
the basis for the alleged exemption. My Wdatbn of Seefbn 70315 by any OU77.E755WI.ICFI6FD(.ILR6 �•
E+ p
applicant fora permit subjecta the applicant to a eivil penalty of nal more than J
E flv undred doll.%5M.
I,as owner of the property,or oy employee with wages as their sole NEW REeiIDFFNTIAL Fd.FK fR QFT. STU1015 TYPE OONSIRLC770N
compens tion,wW dothe work,and thearodure,b not W ended or offend for
5 O sale&e.7014,Burtnm�and Profesabro Code,The Cormado/.Llceme Law
don not apply to N owner of Property who Wilds or improves thereon,and
r.
.he does.uch work himself or th.gh Nsown employee,provded that surfs OCC.GROUP RES.UNITS
impovemerts are not intended oroffcrtd fosle.If,however,the building or TOTAL;
improvement issehl wlthinoaycarofcanpletbn,theownenWtlderwlll have
t men of proving that he did ret Wild or irrrimwe for purpo&e ofaale.). QTY. PLUMBING PERMIT FEE
I,as owner,of the property,am exclusively contracting with Licensed FLOOD APN
mnt,eAt to mrstmn the project(Sm 70"Bushes and Preafubns Code: PFRMITISSUANCE
The Cotndorn License Law dm net apply to an owner of propeny who ALTER-DRAIN 4 VENT-WATER ff1J
Wilds or Improv thereon,thereon,and who m�m afor such p � -
lolewith a ,
rxlDWttoiN Beerued pursuant to the Contnd«a License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
exempt or
U I am exempt Sec. B 6 P C for this rtawn
SC
•
Owner Date
DRAINS FLOOR, _ROOF,AREA,GOND. SANITARY YN
WORKMAN COMPENSATION DECLARATION RECEI T a
❑I hereby affirm aTort
that I have a certificate of co mt to self- ,or � S PER TRV' SCHOOL TAX Y N
mrtNcate of Worker!Compensation Insurance or a certified cc"thereof(Sec. RECEB R
3 ' ab CJ GAS.E.A.SYSTEM-1 INC40Ln= - PARK FPL Y N—
I olky 1 RIKE171"
Cam ` GAS G.S1SSfM-0VER 4(FA) BUILDING DI VE
ISION FEES
['CedlBed
ropy It herebytumWed. GREkSE/INDUSIRL WASTE TNTERCEPIOR PLANCHECK FEE
QCedNed mpy b filed with the city IropMbn division.
CERTIFICATE OF E][EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANT(ARYSTORMEA.10(FT Date Repel til
(Fhbsetlbn mad cad he completed the SURA ti lorone hundred down
($100)oyttu WATTER HEATER W/VLNT/ELECTR ENERGY FEE Y N
I certAytha ti the Srtamance of thewok/orwNch W s Srnut b healed, —
1 shag not employ any Scan In any manner sa asto Mame subfcd to the WATQt SYSIPA(/TREATING
Worken'ComSraatlon laws of California.Use PAID
licant
Z O NOIICETOAPPLICANI'-.1feer ma king this CeriBleate of Exemption,you NEW RESIDENTIAL PLMB. SIT}7. Date Recel t#
P: .hld beeame subject to the Workeri Cornperwtien provbiaro of the Labor - TOTAL:
o
N Code,you mat forthwith comply with such Provisions or this Smut&hall be
K > deemed revoked. 'E
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby aHinn slut there b.mwmttlm IedNgageroy for the Sr(orrry ELECTRIC FEE
Z anoeof the workfor which thin permit b bared(See.3097,CIv.C.) TOTAL -
02 Lender`s Name / , A - PLUMBING FEE
LL ~ IandeU'ti"tss x771 QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1cedltyllutlhave rtadthbapp board rtatethatthc above lnfornatim
M bmrittt.lags to complcuor'.ldtyand muntyb,e representatives
epvanelaws PERMIT ISSUANCE FEES
➢/1)�
N Udall etobuponte abovxdnrn,andhenbyrtyorin rtpesenpurp othis
F Z dryto Wentc, �to see, veemefy an d keepertyforiropatbn p of
ALTER Oft ADD TO LIDCFL - Z
(We)agree m dor,Indemnify an a keep n,rardes the city ar capeAAw Date Receipt,
V .genet llabWtin,Iudgmema,matsaod exSu
res whidr may In anywayattxue AIR HANDLING UNIT(TO IO,ODOCFM) SUBTOTAL:
against said City In conurquenoo gredin ofthbpemnu.
T/ AIR HANDLING UNIT(OVER 10,0D)CFW) CONSTRUC'TIONTAX
Slgnaturt at ppB /Cmtracto Date FJ(FiAl15T HOOD(W/DIKT) CO,�x1$�'f�}.]IeTION X PAID:
URDOUS MATERIAL ISCLOSURE
Will the ap,llcan or future building my est store or handle hrdou HEATING UNIT IW," Date RL'cef IN
material as dellrud by the CuSnlm Munitlpl Cole,Chaper 9.17,and the
lie.lth and Safety Cade Sadism 1.S531W7 HEATING UNIT(OVER ID0,000 BTU) TOTAL:
n Yn Na
ul the app0canto tun WodNS oavP.I use equipment or civ VENTILATION FAN(SINGLE RESTD) ISSUANCE DATE
which eMt ha ,,Jous air rmurnmea&as defined by the Bay Area Air
Qu Ilty Marogemcrt Dbtrltt7 MUER-COMP(3HPOR100,"BTU)
Yes No
Ihave read the hevrdausmateriesrequirements underChaperb%of BOLLER COMP(OVER 100,000 BM
the Cabfamb Health k Safety Cod,Sedbm 75505,B533 and 15534.1 FEB 1 1991
u odeen b
ta cad that if the building donot eurrenthy have a tenant,that It rtry NEWRESIDENTIALMECH. SQFf
resporeibd fty to notify the.part of the requirement.whkh mart he roan
prior to isua me a.cmlfkate Dauer-Y
Q /-L-- 04
Owner or aut lad agent pate TOTAL ISSUED BY:
OFFICE COPY