21037 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building project Identification PERMITNO. -
BuildingAddrea,: 21037
fie ams: one:
CITY.OF CUPERTINO-BUILDING mmDIVISIONp o
ink Cnraenr.Nae No, APPLICATION / PERMIT i-
Sj A&,.j e-oa-es. '(�— 3 BUILDING E.ECTRICAL.PLUMBING MECHAMCAL CATEGORY CONTROL N
Architect/ligleaer. Lic.N. -
... _a,+BUILDINGPERMITINFO
QTY , y ELECTRICPBRM[T, I� i, ��,IFEE ,
Add. - I PERMITIS5UANCE 06 •fes �}(�.
LICENSED CONTRACTOR'S DECLARATION LJ� I sT
Ihereby affirm that son licensed under provisions of Chapter 9(mundencee, APPLIANCESRESIDENTIAL -JOB DLSCRIPTION
Ingwith SeWon7000)of Dlvlsion3o(the Businessand ProfesslonsCode,and my
Iimnseislnfullf andeffed. PANELS
License am LI[.# 4K\� I\� srv�V `�
D.te�a. Cmdrador �r
iAT—
ARCHITEC'S DECLARATION, 201-1000 AMPS
'q�++007. Iundentandmyplameh UB uwdmpubhcmmrds.. OVER 1000 AMPS `.Q.FT.FLOOR EA E/SQ:FT.-
Fe.� Licensed Professlorul - -' SIGNSELEC CAL -
<< OWNER-BUILDER OECLARATION -
In SP LCI(CUITM
U
z o
owing reason.
(Sethat Lmexe5,B from the ed Professions
s License Code:law for t he _
7 following reason.(Section 7031.5,Business and Prolesslons Code:An d or
FZFuy ceontywhichrequiresaperrrdttomvtmd,alteyimpmve,dennlbh,orrepaii TEMP.
❑ nystmdumpeortollsleuanee,aborequimtheapp0antforsuchpermitta
qqq 1m WCR
3K floe a signed statement that he b r9(.licensed pursuant to the tionprovisions of she
u, Contrattofa License law(Chapter9(mmrrencing with Section 700D)of Divi- VALUATIQN
�0 sion3ofthe Buaineasand Proemiom Cole)orthathelseumptthemfmmand C LEL C I
the basis for the alleged exemption. Any violation of Sedion,7031.5 by any ^) O .�S / •B�D,- / �(3 D
applicant fora permit subjects the applicant to a dvil penaltyofnot morethan 2 P b V
'n Cc 1 ffundreddollars1110Q. R DFMi EL TR SQFI. STORI TYPE CON5IRIKTfON
1,to owner of the property,or my employees with wages m their sole '
compematio,wWdothworK'andthestmu mbnot Intended or offemlfor
.sale(Sec.7066,Buslnss.and Professions Code:The Cantd me.Llanse law
docs not applyto an owner of property who builds orimpmes thereon,and, - - OCC.GROUP RIS.LRdfIS
who docasuchworkMmaelf orthmugh hlaown employess,providM thatuch _ '
Improvementsarenotletendedorolfered lorsale.Il,howevcr,the ruildingor TOTAL:
improvemcntissoldwithinoneyeam(compldion,theowner-bullderwill
tf�rden of proving that he did not build or improve for purpose of sale.). QTj. ,'i'PLUMBINC,PERMIT . ,t. .L �:ITEE.'' FLOOD ZONE MIN
1,as owner of the property,am exclusively m.. rg with licensed PERMIT ISSUANCE 0�
metradors to mostrud the project(Sec.7054,Business and Professions Code:
TheContradore License Law does not apply to an owner of property who
buil or Improves thereon, and who contrsda for such p(ojeds with a T ALTER-DRAIN&VENT..WATER(EA) t'_ . FEE
bSUMMARY.. 1 t6
e adoda)licensed pursuant to the Conmador'.License Law.• ggCK FLOW PROTECT.DEVICE.
I am exempt under Sax. B &P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_'
�l�as"" WORKMAN COMPLT4SATION DECLARATION / RECEIPT# a
h hereby affirm that I have a cenlRate of consent to self-Inure,or a ( FIXTURES'PER TRAP ��D� SCHOOL TAX Y - N
c iflateofWorkcn'Compeosallonlmuranuora certified.pythermf(Sec. RECTOR#
3BOD,Lab C.) e� GAS EA.SYSTEM-I INC.40[TILETS. �69P PARK FTE Y N_ v
PoliryN3 2,..'�—I O - RECEI'fp
CAS EA.SYSTEM-OVER 4(EA)
Com anv BUILDINCDI VISION FEES
ffCcrtlfled ropy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR 'PLANCHECK FEE
. Coddled ropy t,filed with the city wpectiondivision.
.t CERTIFICATE OF EXEMPT ION FROM WORKERS' - GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA.200FT. DafC RCOCI tq
(Thlseackm need fid be completed If the permit b forons hundred dollars
(51
I cadifca,a cenl(y that tot the performance of the work forwNch this permitbIssued, WATM HEATER W/VENT/E,F-CTR ENERGYFEE Y_ N
1 shall act employ ani person In any manner u as to become ubjed to the WATER SYSTEM/TREATING '
Workers'Compensation Laws of California.Date PAID
licant
Z Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption, NEW RESIDENTIAL PLMB. SQFP. •Date RL'CCI tN
Hshwld become subject to the Workers'Compensation provlaloin o(the Labor - TOTAL:
f/3 Code,you swat forthwith comply with such provisions or this permit shall be B I G
> deemed revoked.
W — CONSTRUCTION LENDING AGENCY ' FEE
SEISMIC FEE a
(L IFercbyafOrm that them fix a commuetion lending agency for the perform ELECTRIC FEE
7Z anteofthsworkforwhlchthbpermitOWud(See3097,CIv.C.) TOTAL: ,6_�O 33. Ud
UO Lender'sNarde , � ,•, PLUMBINGFEE 6- 00
ly - Lenderaadder. Q . , +'MECHANICAL PERMIT ' :.FEE" MECHANICAL FEE S D
O.W Icenifythatlhavere.dthbappliatlonand M.tethattheabovelnformation `
1 is correct.l agree to comply with all dtyand county ordinances and state laws PERMIT ISSUANCE .1a. FEES PAID:
relating to building westrodlon,and hereby authortae representativesof this -
N city to enter upon the abovo-mentloned property for inspection purposes. AL=ORADDTOMECH. -
Z c to save,indemnify an d keep homeless the City of Cu ped loo Date Receiptf!
V ! ug rot lb Ities,judgrom t expensesvehichnuyln any yacorus AIR HANDLING UNIT(TO IB000 CFM)'" SUBTOTAL:
c' ag Wt Bald By in n en��m]]tf�$NNsI the��// ingolthlspennl[[
' -- kan rt1i4T4o AIR IiANDWNG IIMT(OVER IO,000C[M) CONSTRUCTION TAX '
R1
Date HOOD(W/DUCT) CONSTRUCTION TAX PAID:
1, Sigw of Appl�ican/ roc or EXhL1U5T 6
! HAlARDOUS MATERIALSDISCLOSURE
Will the defined t by the future ruin ngampantode, hhand lc havardoua HEATING UNIT(TO 100,000 BTU) ,Date ROcel W
rnatedaand dally Code Section
Municipal Code,Chapter 9.1 7,and the
flcalt ye, Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ycs No
Wlllthe zppllcanlenre building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISDATE
which emit ha.edoue air contimomnls as defined by the Bay Area Air
OQuality Management Distdd7 BOILER-COMP QHP OR 100,000 BTU) .•I 9(]p -
4 Yes .gNo 1 I99U
haberdt ealth SsfcyCcdal Se requirements 2555,2553 and 25516.95 of RORER-COMP(OVER 100,000 SIU) (� (1.
the CalifomG Health&Safety Cade,Sections 25505,25533 and 75534.1 J�
understand that notify
the
occupant not erequire encs which
that ie Lamy NEW RESIDENTIAL MSCIi. - SQ.FT.
respprior to
net By ureic to of of the requirements when mita]be rrrt; _ City Of Cu:netID0
' prier to Lssuance of Certificate of Occupancy. '
Ownercrauthodred agent -'Date - q - s
'TDTAL: p.SD ISSUEDBY: D
OFFICE COPY'
ICt3o ` S71.0
i(A l- -V0,111III V
I
i � �rilt �� �ie:_.f1i1�41CilCCS ___
\ `•\� c k� FrGrhMC P.I1
APPROV
IN ACCORDANCE WITH T t CITY OF /
Q ERTIN0 CODES AND ORDIIAMCES
$I'NED ��—� 7
This set of p',ans ano spec,6cations.M
be kept on the 1'rtr at r'I times and it is um \
r;;,i; . or alterations
lawful to make fin, gc,armission from v
on same wdh.0 v: su'n " is t no.
the building riep.., C;ty c.f t%ut
The stampingr'r 'h� f'�an 'odspecification
SHALL NUC ue hetl to pe.mlt art an
approval of thr, vu.loo(Al of provisions
of am C q d,i ,m,r ate Law.
' / IOG�! ► s�oK�s
GuPEfZ�a q,� � � pggry�
"tFFIE C0171 SEP 14 1990
II BLDG. INSPECTION DEPARTMEU
CITY, OE CUPERTINQ