21132 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY A oT-3 2
Building Project Identification 0TH -Z PERMITNO.
Building Add 21132
3. 0 6 Vola
neva ams: one: p
' U-g O up CITY OF CUPERTINO-BUILDING DIVISION
C It. or'aN mo: �� �, N : APPLICATION / PERMIT
135f�J BUILDINGELFiCTRECAL PLUMBINGMECHAMCAL CATEGORY CONTROL 0
Archy neer; / Lk. o:
1` tA1.1/ V QTY ELECTRIC PERMIT FEE
ww BUILDING PERMIT INFO
Add.: PERMITISSLEANCE W ® `y 191
LICENSED CONTRtunder CONTRACTOR'S DECLARATION - �f TMJ
I M1thsy flrmthat fDimi1i.n3.fhn B..Irov4lonsof C,sIor. de,srdn APPLIANCESRESIDENML JOB DESCRD'r10N
ingwiflom.h I.f.U.,rr)of Dlvielan3oflheguelneuan���IPP'rmmvleatlmsCode,and my
Ilansie in fug ggqqqrrrrrccccmeeee and e0ect PANELS
5 FA w L
Lace C Lk.p
Dale Contractor
ARCHITECT'S DE LARATION 201-1000AM1S
pO I understand my plane ohs0 be used as public records. OVERIODOAMPS SQ.FT.FLOOR.AREA $/SQ.Fr.
Llansed Professional SIGNS ELECTRICAL q )I/
OWNER-BUILDER DECLARATION
z.�j� IherebyafBrm
mtlutIaexemplfromnt
theCoractor'sLicenseLawfmSPGCULCIRCNT/MLSC
the
following reason.(Section 7ml5,Business and Professions Code:An city or
Fq., county which requires a permit to castmct,alter,Improve,dentalish,or repair 1'QdP.METIX OR PO7-E INST.
v any structure prior to its Issuance,also requires the applicant for such permit to
O ilk a signed statement that he or licensed pursuant to the provbaom of the POWER DEVICES
µ�+ Contra mrb Li..Law(Chapter!)(mnurcncing with Section 70M)of Dlvi-
�,�0� sion3ofrhe Bueheae and Protessiore Code)orthat helsexemptrherefromand SWIMMING POOL ELECTRIC VALUATION
the bash for the alleged exemption. Any .vlolatlan of Section 70315 by any
<� applianl for a permit subjects the applicant to a civil penalty of out room than OUTLETSSWITCHESFIXTURFS
five hundred dollars(5500), t
C]1,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPECONSTRXTION
< compensat(on,w(lldothe workandthentructure Isnot intended or offered for d
O sale(Sce.7064,Bushesand Professhrry Code:The Contractoes License Law I L
3$ does not apply to an owner of property who builds or Improve,thereon,and OCC.GROIIP RES.UNITS
who does suchwork himself or through Ms own employees,provided that such I
Improvements are not Intended oroffered forsale.If,however,thebuildingor TOTAL; f
improvement keoid within one yearof complello4the asvncrbulMerw111 have
133ecrden of proving that he did nm build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEEETOOD7ONE APN
11 L as exam,of the property,em exclusively contracting with licensed pp rprm tpNCE
contractors to construct the project(Sec.7044,Business and Professions Code: 4
The Contrector's License Law does not apply to an owner of property who ALTER-DRAIN A VENT•WATER(EA)
builds or Improve thereon,and who contracts fm such p(ujects with a
co ctor(s)Boomed pursuant to the Ctrachar's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I m
" am exempt under Sec. B k P C for thin reason
Owner Data DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N=
WORKMAN COMPENSATION DECLARATION RECEIPT 0
❑I hereby affirm that I have a artiRcate of consent to self hature,or a FIXTURES.PER
TRAP SCHOOL FAX Y_ N
certlflcateo(Workers'Compesatlonlmuranmaramnifkdmpythert f(Sec. RECEIPT
380D,Lab C.) GAS FA.SVS(EM-I INCA OUTLETS PARK FFP Y_ N
I'oliry p RECEGAS FA.SYEETM-OVER 4(EA) DING DIVISION
M
Com any BUILDING DI VISION FEES
[PCerllRed copy is hereby fumishei. GREASE/INDUSIRL WASTE INTERCEPTOR P 1ECKFEE
❑Certl/Ied copy b,filed with the city Inspection division. ^
CERTIFICATE OF EXEM(TION FROM WOR KERS' GREASETRAP PAID a/{L
COMPENSATION INSURANCE
(rhissectlonneed notbscomplctedifthepermit be for one hundred dollars SEWER-SANITARY-STORM EA.20OFr. RecelptO Pliiew
(SIOD)oWATER HEATER W/VENT/ELECTR ENERGY 'EE Y N
Imrtifyify that hthe perfomunaofthe vrmkforwhkh/hb permit is lswed, —
I shaft nw employ any person In any manner so s to been.subject to the WATER SYSTEM/TREATING
Workers Compam.amn Lawn of Call I.. Date PAID
Q Z Applicant Date Rccei tq
Z O NOTICETO APPLICANT-.U,after rtuking this Certifier.of Exemption,you NEW RESIDENOAL PLMB. 9QFr.
Fshould becomesubject to the Workers'Comperestlon provisions of the Labor TAL:
tl3 Cade,youmustfonhwlthmmplywlthsuchpmv ioru orthlspermItshallbe
2 > deemed revoked. ' !SEISMIC
LDING , �-a Ida
ILF3 CONSTRUCTION LENDING AGENCY FEE Iherebyaf0rm thattherek a construction lending agency for the perform. CTRIC FEEZ once of the work!or which lhls permit ls lsued($ee 3097,Civ.C.) TOTAL:O lender's Name MBING FEE _LL H Undue.Addr.s QTY. MECHANICAL PERMIT FEE CHANICALOW Icertlfythatlhavercadthisapplicatlonand gate thattheal, InformationO. lecomed.I agree to comply w0hall dlyand countyarellaantts and state laws PERMrr jZ (b' S PAID:
>- W relating to building construction,and hereby authorize representatives of this �d
t Z city to enter upon the abovcmentlonei p eny fmI pectlon purposes.. ALTER OR ADD TO MECH. Date Receiptp y{4�
V (We)agree to s ,IndemN n harMes the CI of Cu ertlno
agaWt0abl0tl dgmenls, a nae' hlch ney lnanywayac AIR HANDLING UNIT(r010,000 ) SUBTOTAL.
.8= 1 In con enrl of rhlc p.mtit.
Airs IiA WNG UMT(OV 1 ) CONSTR ION TAX
gMNre Af t/Conrrctor D(W/D CONSTRU A
HAZARDOUS MATERIALS DISCL(
Will tis applicant or future building occupant store or handl hazardous I4EA UNIT(!!Dr,�O BTU)
material as defined by the Cupertino Municipal Code,Chapter .lZamithe Date Reeeiptq _
Iiealrh and Safety Code Section 25532(,)? I pf0 100,000 BTU) TOTAL:
n Yee �]Na
ill the applicant or future building occupant use equip atordevices VFX FAN(SINGLE RESIU) ISSN A `
which emit haru rdous ah coma mlranrs as defined by the Ba Arca Air .J 1467
Quality Management District? BOILER-COMPOEE'OR l00,IXD BTU) 19°1
Ye, ❑❑No ((��D f .7
have re ad the hazsrdoua rtuterials requirements under apterb.95 of ILER-COMP(OVER 100,000 B s`
the hllf ant.Health k Safety Code,Sea tom 25505,25533 an 25534. I
u aderda ad that if the building does not avrcnrly have a tens. thatltls my NEWRISIDENrIALMECIT. SQ.IT. "Fr"'xx.•
responsibility to notify the occupant of the requirements which the mM a
prior to issuance of a CertlBak ofOccupanry.
Owner or authon xcd agent Date ISSUED BY:_
TOTAL: �
OFFICE COPY