21129 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY �pl
Building Project Identification 1PITT NO.
Building ddreac1 0 ( PLFRu R[cV-13v, 21129
n erre. one: p
�"�(-}Q��,..9j G-QO(�� CITY OF CUPERTINO-BUILDING DIVISION o
. c°�Ir�ary�r°N. LLJkC" 'Q APPLICATION I PERMIT
�fAns- DIIbaV4Slu 17h7�J BU LDINGELECTR CALPLUMBINGMFfHAMCAL CATEGORY CONTROL M
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE h I t7/
^l 1
irmthaSF.DCONTR under eDECLARATION Ihth Se a.flrmthalanthem3.fth derprovialonso(Chapter de,.adm APPLIANCESRESIDENITAL JOB DESCRIPHON
Ingwith Section 7000)of Dlvielon3otlhe Bualnessand Pm(esslansCnde,and my
licenselsln ful o and d(M9 pis S FD w L
Licen C LIC.II
Date Contractor ow 6-1 LIPT0200AMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
�pp�vv NO Zp I understand my plana shall be used as public records. OVERIODOAMP9 SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional 9CNSELECTRICAL "1 2�C / Ff
y<w<< OWNEReBUILD ne DECLARATION SI+ECJpLG7RCUIT/MIEC C�, L� lL
Thereby afOrmthatlameaempt ERDEeLARATor's License law lor the 'T
qqqqqq following reason.(Section 7031.5,Business and Profesaons Code:Any city or
countywhkh requireaa permit tomrotract,alter,Improve,demolish,orrepair TFMP.MEfER OR POLE INSf. r
4 asa any°tmm.p i.,toitsissuance,al o.q.t.theappUmnt(wr chperMtto POWER DEVICES
6 O U file a signed statement that he at licensed pursuant to the provixiona of the
µ Contactors License Law(Cho pter9(commencing with Section 70W)ofDivi.
�,�OS don 3ofthe Buslnessand Peafmmes Codc)orthal he at exempt therefromand SWIMMINGPOOLE.ECTRIC VALUATIOI�O
the bast,for the alleged exemption. Any violation of Section 70315 by any I .j S ^ CJ
appH.at fora permit subjectstheapplIcanttoa civil penalty ofnd morthan OUMETSSWITCHESFI%TURES
five hundred dollars($500). NEW !RESIDENTIAL ELECTR t
�n ❑1,as owner of the property,or my employees with wages as their sok SQFC. SCOW FS TYPE CONSTRUCTION
compensatlon,wRld°the wor"rulthestmature is not intended or offered forO
O .1.(Sec 70K Business ad Professio.Code:The Contadols License Law ,
' $ does not a pply to an owner of property who builds or improves thereon,and OCC.CROUP RES.UNITS
who does such work Mmlf
seorthrough his own employees,provided that such Q
Improvements arc not Intended orofferedfrreale.If,however,thebuilding or ' TOTAL:
improvemdMisadd within oneyearofcompidiorythaowner-buaderMll have
t"eden of proving that hedld not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE pLOOD70NE APN
LJ L as owner of the property,am exclusively contracting with licensed roPERMITI$SUANCE I^1�.
contractors to md truthe project(See.7014 Business and Professions Code: A
The Contador's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptujeds with a
cgR(Caetor(s)Iksneed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for that mason BACKFLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,CONT). SANRARY Y N
• Owner Dae RECEIPT M
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
❑I hereby affirm that 1 have a cert1(Iate of consent to copy thereof
ora RECEIPT Y
3800,Lte ab
Worken'Compmsatlonlnuunnce oracertified ropythemeo(ISa. GAS PA.SYSTEM-1 INCA OITLM PARKFFE Y N
3800,Isla C.)
Policy p GAS FA.SYSTEM-OVER 4(RA) RECEB'T'X
Com any - BUILDING DIVISION FEES
FCerd ied copy is hereby th the cid. CREASE/INDUSI'RL WASTE INTERCEPTOR P HECK FEE
❑CertVled copy V(Ikd with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAI
COMPENSATION INSURANCE SEWER SANITARY
(Ihlsamthm.eednutbecompleted lftheperretatforaaehundeaddollan STORM EA.200P1'. Dat Recei t#f^Sa'QJ
(f1I ormlass. VENT
Icert yth) In the performance of the work forwhkhthls permit ie blWATER HEATER W/ /E.ECTR ENERGY FEE Y_ N_
I shall not employ any person In any manner so as to became subject to the WATE(SYMI M/TRFATING
Workers'Compensation Laws of Califonels.Date PAID
-
Z Z Applicant
Z O NOTICE TO APPLICANT;If,after nuking this CertRlate of H.em)nlon,you [v`Lv`'RESIDENTIAL I'LMB.__SQFf. Date Revel HI
Hshould become subject to the Workeri Compersatlon pmvbiomoflhe Labor TOTAL:
MN Code,you at forthwith comply with such previxi.s or this permit shall be 0
LU > deemed revoked. BUILDING FEE O
CIL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the pedarm- TOTAL: Q
Z ance of the work for which this permit at iwM&c.3097,Civ,C.) t Q ELECTRIC FEE
0O Leaders Name PLUMBING FE' p 0
LL F Lenders Address QTY. MECH CAL PERMIT FEE MECHANICAL
O W Icedlfythatl have read thatapplicatlonandstatethatihrvbo a aformation aanapsa a
1 atmrreci.]agree to comply with all cityand county ondinancesand state laws PEtM ANCE n n.L/ PEES FAIL):
N relating to building coedeactlon,and hereby authorize representatives ofthls
I" Z Illy to enter upon the above-mentmsedprops orlvpMlonpurposea. OR ADD TDME'LH. Date ReCei [N T
agree to ea demnl and a ess the Clty of Cupedlna
against llabillt meat°, sae aw horsy In any ways c AIR HANDLING UNIT 10,000 ) SUBTOTAL:
against moon o x ti his permit. AIR HANDLING UNIT(OVER 10,000 CN) CONSTRUCTI TA
3/
nature of rat/Contractor to IXHAUST HOOD(W/DUCT) CONSTRUCT
HAZARDOUS MATERIALS DISCLOSU
WBIt applicant or future building occupant stamor handle h edous HEATING UNIT(TD 100,0008
material as dented by the Cupertino Municipal Code,Chapter 9.1 andthe Date Reeei tH
Health and SafetyCade Section25532W7 HEA'UNG (OVERI 7'U)
TOTAL:
❑Yes �]No
Will the haeardntarfuture
contaminants
amnpandbyequip mea devices V AN 'G RESID) I ODATE/L-"�'
whichemit havmloua air rontaminanta act de0ned by thea Area Alr
. Quality Management Dietrict9 ROIL MPO 0 ,000 BTU) ����
Yes I�I No f�PR
have readthehazar�ous rtutedalsmqubemenhund rChapterkl)So( -COM 100,000BN)
the California Health k Safety Code,Sections 25505,2553 and 25534. 1
uaderstandthatlfthcbulldingdoean°Immentlyhavcat eanLthatitlamy, RESTDENTI LMECH. SQ.Fr �a[Pmr... s
rnpomlbllity to nollty the occupant of the mqulrementew ch mus[be met rlr/
prior to issuance of a Cenificateof Occupancy. Q
7 11
Owner or authorlud agent Date O ISSUED BY: s^—
TOTAL:
E COPY