21947 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ,
Building Project Identification PERNOT NO.
Building Address: • - 21947
1 9 4 7 '
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Wl,era ' One: .. - ..
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CITY OF CUPERTINO-BUILDING DIVISION G
Contractor's Name: Lic.N. APPLICATION / PERMIT-
OaeefL �-O
BUILDING-,aECTRICAI PLUMBINC-MMC LAICAL CATFLORY CONTROL X/
'. Architect/Gglneer. Lic.No: - - b l
I It, ' '" 'F, -;BUILDING PERMIT INFO''' --
�pTY,' ELECTRIC PERMIT i FEE 1i•
Address: , 1
. `' PERhETI55UANCE '. ZC� 1g] 1:1,LICENSED CONTRACTOR'S DECLARATION -
I herebyaflmthatlansed er r aPof Gpter9(mmmenc APPLIANCES-RESIDENTIAL
inithSiAWon3oftheBusiessandrofeaslonsCode,andmy
license is In WH forceand died. JOB DGSrC.AB'IiON
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PANELS
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License Clan Lie M
Date P S �.1 Q•.A .(/(�nr
Contactor
ARCHITECT'S DECLARATION 201-1000 AMI5
re0 O I understand my plaroshall be used u public record.. OVER TWO AMPS " SQ.IT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL'
6 w OWNER-BUILDER DECLARATION
Ci SPECIAL CIRCUIT/ LSC.' -
F^ /hereby afBrmth6tlam exempt(romthe Contractor's Linnen Law for the
7o following reason.(Section 70315,Business and Professions Code:Any city or TEMPMETQt ORIs4f.t I`
O Z H . ..
P� countywhich requBesa Parrett corutruct,alter,improve,dennlbh,or repair _
anystructure prlortolts Issuance,also requlrestheappilcantfor such permit to POWER DEVICES• .Z
rNG file a signed statement that he b licensed pursuant to the'provisloru of the
3w Contraciorb License Law(Chapter 9(coerm.cing with Section 700(l)of Dlvl- '
SOS slon3 ofthe Business.nd ProfesslonsCode)mrthat he is exempttherefromand SWIMMING POOL ELECTRIC VALUATION
�'s the bask for the alleged exemption. Any violation of Section 7031.5 by any 0ES
Qappllant for a Fermat subjects the applicant to a civil penalty of not morethan -
- five hundred dollars($$00. -
F11,as owner of the property,or my empl yeee with wages as their sok NEW AESIDENHAL ELECTR SQ'FT. STORIES TYPE CONSTRUCTION
compensation,will do the work and the strucWre b not Intended or offered for
Osale(Sec.7U4,Buelnms and Professions Code:The Contractor's License Law
r3•S does not apply to an owner of property who Wilda or improves thereon,and - RES.UNITS.
EEEE who does such work himself or through his own employees,provided that such OCC.GROUT'
improvements arc not intended or offered for sale.If,however,the building or ,TOTAL: c
improvementb, within oreyearofcompletlom,theowner-bullderwill have , . -
c rdenofpmvingthat hedid not Wild orlmprove for purpose ofsakJ. QTY: 't1. PLUMBING.PER11'IIT, ?. ,, FEES, FLOOD ZONE APN
as owner of the property,am exclusively con......ing with Iiansed PERMIT ISSUANCE
ntractors to construct the project(Sec.7044,Business and Nofessloru Code: ' -
e Contractor's License law does not apply to an owner of property who
IMO or Improve thereon,and•who contracts for such projects with a ALTER-DRAIN&VENT-WATER IRA)
�6t[+sorts)licensed pursuant to the Contractor's Llm,ue Law, FEE SUMMARY
LJIdam exempt under Sec B &P C for this reason
BACK FLOW PROTFLT.DEVICE
- OUTSIDEFITS
MFDCfURES-
OOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION ' PER TRAP SCHOOL TAX Y N❑I hereby affirm that I have a cortl0ate of consent to self-Insere,ora RECID'f Xcertificate ofWorkers'Compensation Insurance ora certifled cepythereof(Sec. YSTEM-11NC.40I11LET5 PARK FEE YN3900,Lab C.)Policy X REC=IF
YS1T m.OVER 4(EA)Com ny BUILIIINC DI VISION FEf.S
[PCenined copy k hereby furnished, DUSTRL WASTE INTERCII'TOR PLANCHECKPEE
❑Cedified copy k filed with the city inspection division. 6ns 7S
CERTIFICATE OF F](EMIFFION FROM WORKERS' AP PAID
'COMPENSATION INSURANCE - MTARY-STORM EA.20OPT. Date, .RL'eel tgQhlssectionneed TIObecompletedN INSURA Is(pronehundreddollen '
(SIM)or less.) WATER F[EATER W/VENT/ELECTR ENERGYFEE Y N
I certify that fu m
the perforanceof the work for which this permit Is Issued, ^'
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING 1"
Workers'Coerpemation Laws of California, Date PAID '•
.0 Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei t7
0: NOTICE TO APPLICANT:ILafter making this Certificate of Eeem)Hlon,you
should become subject to the Wmrken''Comperuatlon provisions o(the Labor TOTAL:
W Code,you must fort hwith comply with such provisions or this permit shall be OLsus� D
CL G
LU > deemed revoked. - BUIL NG ^
CONSTRUCTION LENDING AGENCY SEISMIC FEE .S
Z I hereby af0rmthat there is a mnstructlon lending agency for the perform TOTAL: ELECTRIC FEE .CYJ
Once of the work for which this Perrot is Issued(Sec.3097;Civ.C.)
(•,)'O Lender:Nares PLUMBING FEE '
IL F Lenders Address QTY. MECHANICAL PERMIT "FEE MECHANICAL FEE
OW I certlfythat l have read this application and elate thattheabove lnforrrution -
S is correct.Iagree to comply with all city and county ordinanaaand sate laws PERM[f ISSUANCE FEES PAID:
} N relatingtobulldingcuTt% on;end hereby authorize representativesofthi. "
,F Z tity to enterupon the
cmentiormd property forinapeatlon Eu rposes, ALTER OR ADD TO MSCH.
V —
Me)agree to save, dcmnify anVk./pheas theCitylal?j
PX noDa[e .. RecejptMagalnstllabilitic * d nts,m ah may in arue AIR HANDLING UNIT(TO lOWO CFM) SUBTOTAL:X.
againstuld Ci n c f Mhla permit. - '
AIR HA NDLING UNTF(OVER I O,WO CIM) CONSTRUCTIONTAX
g,a P Id ontr cto Date EI(13AUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Willtheapplia or forum building ompaN store or handle hazardous HEATING UNIT ITO 100,000 BTU)
nDate RCCCi tN
uterlalasdefi by the Cupertino Municipal Code,Chapter 9.12,and the -
llcalthandSafety Code Section2S532(a)? KEATING UNIT(OVER l00,000 B7U) TOTAL' x
❑ Yes �i No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINCLE RESID) - ISSUANCE DATE
hich'eMt hazardous air contaminants as defined by the.Bay Area Air A
ality Management District? BOILER-COMP 0II'OR 100,01W BTU) �t
u Yes n No
ihavemadthe11. O l.ieriakrequlrement.under Chapter6.95of BOILER-COMP(OVER 100,000 BN)
the California Health&Safety Code,Sections 25505,25533 and 25534. I D J�
understand that lfthe building does not currently have cotenant,that it is my NEW RESIDENTIAL MECH. �,1{AY SQ.FT. - Mx'1`
responsibility to notify the occupant of the requirements which must be nut ^
prior to Issuance of a Certificate of Occupancy. - _ _ ��.of,CU
y Owner or authorized agent Date + TOTAL: ISSUEDB VNYfY\,
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OFFICE COPY