21858 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm Idemiflotlan 7 PEILMITNO.
Building Add.:
P 21858
2o7+joV'tl r..,� �/ R•.-0 aso44 Sem
entre ante: W I 1$'^ one APP=ff61TM7M=DATE
G CITY OF CUPERTINO-BUILDING DIVISION
Cmttractor's Name: Lk.No: APPLICATION I PERMIT L— 2Z
BNLDINGELWMCALPL(IMBINGMES:HANK.ALGTFLORY CONTROL I/_
Aemues:/ r. Lie.No: G�
Q ELECTRIC PER FEE' BUILDING PERMIT INFO
A
POWTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECL ttATION
I hereby affirm that l am Beenaed under prwblau of Chapter9(mmmat APPLIANCMRFSIDENTIAL JOB DESCRIPTION
Imgwith Seet1m700))ofDWLdan3ofthe Bufneaaand Profenlo sCode,and my
Doen.,e b In fullfore and effect. PANELS
Ll ruo Clara Licl'
Date Contractor UP TO 2DOAWS
ARCHITECTS DECLARATION 201-10DO AMPS
0'Z l understand my plaro shall be used u public records. OVER I ODO AMPS SQ.FT.FT.00R AREA S/SQ.FT.
WWWWO
" LicencedPrmmbnal SIGNS ELECTRICAL 7700
'zY OWNER-BUILDER DECLARATION S1PECIALCIRCUITIMLSC
t.., Thereby afOem Uut I am exempt from the Conductor's Llan:Law for the
ZQ following reuon.(Se Non 90115,Bualem and Pmfeabne Code:Any dty or
K� muntywhkh rxxrylrnapermlttomudrucl,alter,Unpmve,dennleh,or rtpalr TQAP.METER OR POLE INST.
anyatme en prlortole houanee,alto requbesthe applicant f«such permit to POWER DEVICES
Ne•signed statement that he b Licensed pursuant to the provblom of the
. Oz Contractor's Liceme law(Chapter 9(mmmeneing with Section 70011)of LTM- SWIAh9NG POOL ELECTRIC UA
sbn3ofthe Buainmand Pro(mbro Code)orthatheltexamptthercfmmand VALTION
the basis for the alleged exemption. Any violation of Section 707LS by any q
<� OI177.EI"'.'"N77CI ESSFUfC[1RFS
applontfora permit subjeb the applkantto a civil penalty of net more than
five hundred dollars($500.
❑I,u owner of the pmperty,or rrry employee with wagn u theb mit NEW R®FN77AI'F1'ECIR SQ W 6 TYPE CONSTRUCTION
C>Q eumpewtion,wllid0 thework andthe Yructumbmtlnlended or offered for
5 O sale(See 7Mq 1.4 andP mbu Cade:The CoWn=eaWanae Taw
donrutapplytoanowna of property who builds or Improves thereon,and OCC.GROUP RES.UMTS
who doetauchworkml
hisemthmagh hisownemplo/m,provided thatwch
hnprovementa are not intended oroffered f«sale.If,however,thebulkling or TOTAL:
Improvement baold withinorayearofeampletbn,the owner-builderwW have
tt u'dpn of proving that he did not band or improve f«pu rpoae of uk.). QTY. PLUMBING PERMIT FEE
r•(�tr Liu owner of the property,am exchutvely contracting with Keened FLOODZONE .APN
can ms to consumd the project(See 7DK Budnmard Professions Code: PERMIT U JANCE
The Comrsdorl License Law don not appN to an owner of property who
butda or Improve thereon,and who mrMncta fee sueh pPjeos with• ALTER-DRAW 4 VENT-WATER ff.V
cqnjp
L_jI
e
tor I pursuanttheCtractor's License SUMMARY
rue Taw.
LJ I int ummpt pt under Sec mwB k P C for this, w�n HACK FLOW PROTECT.DEVICE reaOUTSIDE FEES
DRAINS FIOOK ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT Y
WORthat COMPENSATION DECLARATION
r-11I hereby affirm
that I hm•aMlOate of mnaent to aelFiwrt,or a FIX7VRF5'IPER TRAP St7{OOL TAX Y NREC _
¢mNaof Workers'Campewtlon Tmuran¢«a¢nlfled mpythercof 6ec. TIPT T
3800,
Lab
C-) GAS FA.SYBIDA-t INC4OUTLEIS PARK FEE Y_ N_
RECEIPT 1
��a GAS EA.SYS OVER4(EAI
Co ny BUILDING DIVISION FEES
�Cerllllei ropy b hertbyth the d. GREASE/INOUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑CedNed ropy lt filed with the c0Y Ivpe[bn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
b for orae Aundrcd dollars SEWER-SANITARY-STORM EY.200FT Date Recei t#
( section mood mat be completed Ithe permit
moD)mor«Im.) WATER HEATER W/VENT/ELDCTR ENERGY FEE Y_ N_ sV_p
I¢e�ify that Nthe pernnIaofthewmk so an tobthiopemdtIs claced,
I slut not employ any peawa In any manner at u to become subject to the WATER SYSISM/TREATING
Workere'Conipansubn Iowa of California.Date PAID -
Z O APP
RESIDENTIAL IB. Date Recei t#
NOTICE TO APPLICAMI,after making this Certlt¢te of Exemption,You NEW SQFT.
ahaild become subject to the Workers'Compewt ion pmvbbns of the Labor TOTAL: 23
~ N Code,you rrun forthwith amply with such provbbm or this permit ahall be BUILDING FEE S-0
deemed rooked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I herebyaNrmtFw thercba ermtructitated( ngagcruybrlhe Perrone. TOTAL: ELECTRIC FEE
7 Z ance of Lendee Nwork for which colt permtt bbaued(Sec 3097,CIv.C.)
LL O Larders Name PLUMBING FEE
LL ~ Lendde Addrm QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW I¢ftfythrtlhave read thbappllutbnand fatethrtthe above lnformatimn
d bmrrcct.Iagneto mmplywhhaldtyand county ordlnanmand fate laws PERMIT ISSUANCE FEES PAID _
} N relating to WlklingmrutructIan,and hereby authodre reprnentrtives ofthis
F Z dty to entarupon the a roentbmd properryfmimpectlon purpmn. ALTER OR ADDTO MEGH.
(We)agree W nave,bdemrdfy and keep hamdm the Cfty of CuperlLw Date Reeei t#
V agatrmt llabNtks,wdgmerds,mfsand expereeswhkh mayln aeyway..e AIR HANDLING UNIT(TO 10,ODDCFM) SUBTOTAL.
ageiut d City in rovuqumea o(the granting of thio permit -
AIRIiANDutJc 11N11'rovIR ID,ODO CFM) CONSTRUCTION TAX
gruture of Appl mitran« m F7UTAUSI k O u m/DUCD CONSTRUCTION TAX PAID:
RDOUB MATEl1ALS DISCLOSURE
Will the applian future building oeeupant store or handle havrdcu 'I HFA UMTt'1D 1DD,LD0 BTU) Date Recti t# ZZ,.. .
material as deleed by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code SMIm 75532(.)7 HEATING UNIT(OVER 100,(10)BTU) TOTAL:
&T-
Y.
❑
WBllhe.,pplloMar turcNobulldinga ' pantuuequlpmemendevkm VEN111AT10N FAN(SINGLE RESID) ISSUANCE DATE
which emit luurdous air conlambunts as defined by the Bay Arta Air p
Quality Management DW r et7 BOILER-COMP OM'OR IOQDM BTU) Y'_
Y. No Y
have mad the haw our ruterlab requlremenb u nder Cha Iter 6.95 of BOILER-COMP(OVER t00,OLD BN)
the California Health k Safety Code,Sc tioru 25505,5573 and 2553/. 1
understand that if the building don rM seemly have•tenant,that It is my NEVJ RESIDENTIAL MECIL SQ.Fr.
rmporm@lily to nett(,the occupant or the requirements which rust be met
prior to bsuancc of a Certillate of OaVparey.
Owner or aulhoriad agent Date ISSUED BY.\TlC/IC\\\ .4J��'e
TOTAL �
OFFICE COPY