21532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ee IdentificationPERMIT NO,
Budding IAddnss:q 43 t4c3" Stupe) .. p „ 1 21532
nm".ULE S1E'J '�--, one. CITY OF CUPERTINO-BUILDING DIVISION A A A
y'�4�t�Jy ChJY L o, APPLICATION I PERMIT
BLnDINGELECTRICAI PLUMBINGMECHANICAL CATEGORY CONTROL
N(�•J���(/ /'� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A . d^ •tea E.6V`-- PERMITISSUANCE ❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that lam Bcensed under providersof Chapter9(comment. APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
ingwith5,ctton7000In 'vlslon3 ofthe Buslnessand Profess).nsCode,andm
license is in (ect. PANELS
Lice. C e# 1lJ
Date ContncioUP TO 200 ANU'S
IFRCHITECP 201-1000 AMPS
Q CTOC I undo rind my plaru shall be used as public records. OVER 1000 AMPS SQ.F7.FLOOR AREA 5/SQ.Fi.
0 U Licensed Professional WAL
RICA
�Q� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
7ti Z IherebyafRrmthat l am exempt fromthe Contractor.License Law for the
Q fallowing reason.(Se tion 70315,Business and Profession.Code:Any city or
0 I"� county which requires a permit to construct,atter,improve,demolish,orrepair POL
S.0 any structure prior to its Wua me,also requires the applicant for such permit to
1 U file a signed hocerent that he is licensed pursuant to the provisions of the CES
30F^ sloo3o( vl-
hesBvainenand cense LawProfeslowCoder 9 e)orthnghebe with monthercfrom�nd VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any 'TC FI
applicant fora permlt subjeca the applicant to a civil penalty of not noose than
five hundred dollars($500). t
I,as owner of the properly,or my employees with wages as their soleAL .FT. SCOW ES TYPECONSIRUCTION
mpensation,wRldothework andthestructure bnuthemoded or off,red(or
O sale(Sec.M6 Buitimmand Professions Code:The Contractor's License LawMI$$ does nm apply to an owner of property who build.or improve.thereon,and
who d.essuch work himselforthrough his own employees,provided that suchOCC.GROUP RF UNITSImprovements are not Intended oroffered for sale.It,however,the Wilding orTOTAL:
Improvement.sold with In one ye...fcompletlon,the owner-builderwlll have
t)4kurdcn of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE F'IgOD70NE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE h
contractors to construct the pmjee(Sec.7044,Business and Profession Code: 1..
The Cont racor's License Law does not apply to as owner of property who
buildsALM-DRAIN k VENT Wor Improves thereon, and who contracts such plojeox with a - ATER(EA)
c%itacor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT,DEVICE FEE SUMMARY
U I am exempt under Sec. B k P C for this reason
• Owner Date DRAINS FLOOR ROOF,AREA® 'Zx�' SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
01 hereby affirm that I have a certificate of consent to.elf-insure,ora FDT�s P131 TRAP CfCM SCHOOL TAX Y N
001ree.fWorkeC.mpensad.nlnurance cars<edifled (Se
copythere.( c. RECEIPT#
MGAS EA SYSTEfl INC OUTLETS
3300,L.Lab C] PARK FEE Y N
1'oliryp T�/
xECEIPr p
C. y .1 N' GAS FA SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Codified copy b hercbytumcityed.Inspection dl
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy V filed with the e ddivision.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(I'htssecti.n need not becompleled tithe permit bforonehundred dollars SEWER-SAMTARY-STORM EA.2001 Date RCCei t#
($1m).r les.)
I certify that In the performance ofthe work for which this permit is blued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
1 shall not employ any person in any manner so ns to become subject to the
Workers Compensation Laws of California.Date WAIIM SYSTEM/TREATING
O Z Applicant PAID
Z O NOTICETOAPPLICANT:If,after mekingthLs Certificate of Ex co fon,you NEW RESIDENTIAL PLMB.__SQFx Date Recti t#
should become.ubject to the Workers'Comperwtlon pmvbion of the Labor TOTAL:
W~ N Code,you must forthwith comply with such provision or this permit shall be
? deemed m"Oked' BUILDING FE '
a. E3 CONSTRUCTION LENDING AGENCY
Z SEISMIC FEE
I hereby affirm that then le a construct.,lending agency for the perform ELECTRIC FEE
ance of the work for which this permit is Issued(See.3097,Civ.C.) TOTAL: 1 �
(-) 2 tender.N.me 1• sPLUMBING FEE
IL F Iender.Addmss QTY. MECHANICAL PERMIT FEE '
O w I certilythat l have read thisappllcati.,andaawthdtheabove tnformaHw MECHANICAL FEE
1 Is correct l agree to comply wdhall city and countyordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this h Z city to enter upon the above-mentioned property for Wpwom purposes. ALTERORADDIOMECH.
— (We)agree to aave,indemnity an d keep harmless the City of Cu ped Inca Date Receipt#
agai etllabilitica l�dgments, sand ext,enseswhlch mayinapermit.n wayaccne RHANDLINGUMT(rOI0,000CFM) SUBTOTAL
taxi in n all ce o h of this
� AIARHANDLNGUMT(OVFRIO,000CFM) CONSTRUCTION TAX
Signamreof Applicant ntractor Date EXIIAUST HOOD(W/DUCD - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllca not or future building occupant store or hand le hazardous- HEATING UNIT(70 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCej f#
ilealth❑yea SaletyC moon 2S532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL: s.W
Will the applicantor tore bu riding occupant use equipment or devices VFNII LATION FAN(SINGLE RESID) ISSUANCE DATE
QoMfty M.rvgzdlom. contaminsnts as de0ned by the Bay Arca Alr -
QualityMangement is BORER-COMP(3FI'OR 100,0M BTU)
Yes o o
1havereadthehaza ousmaterialtroulmments un derChapter6.95of BOILER-COMP(OVER100,000 RTU)
the California Health h Safety Code,Sections 25505,25533 and 25534.1 DEC 1'i 1990
understand that if the building does not otmuntly have a tenant,that it kmy NEW RESIDENTIAL MECH. SQ-FT
rrs roNilit to ify the oca ant of the requirements whichthe rret
01 o^
F� �f,rrl' trda
Owner.rauthmized agent Da ,a•6 r.,.., .
TOTAL: ISSUED BY: �1`�r✓P 1 xt'�P''' ''Cl1
OFFICE COPY