21473 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proud Identification PERMIT NO.
Building : aw/Tr �R cr �'v�� 9. o i� 21473
nems come: y ,qonr
I WATSQ(V 4E�J`7 q CITY OF CUPERTIN0.BUILDING DIVISION
Contacma.Name: Lie.No: APPLICATION / PERMIT
OMDINGELECnUCALI'LUMBINGMECIIANICAL CATEGORY CONTROL Y
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING
PEPERMIT INFO
ress:
Add - PF"TISSUANCE `I�7 1:1 ❑
PLUMB M1LH
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that I am licensed rovWomof C9A[tIIANCESRE9DENiTAl JOB_Q
B(
�DF�SC
IngwithScetion 7000)ofDivfigon 3ofthellusnesfandProlnssionsCode,and my
lt...1s 1.full to"and effect., ON e
PANELS
License Ch® Lk.Y /
Dale Contractor a
ARCHITECPS DECLARATION 2014000 AMPS
q�u DCO I understand my plans shall be used as public records. OVER1000AMPS, SQ.Fr.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNSELKIPNAL
666�<(P6TI OWNER-BUILDER DECLARATION SPECIALCIRC MISC
Iherebyaffirmthatlam...mpt(roes the Contractor's License law for the
O Z following mason.(Seal,7015,Business and Professions Code:Any city or �p M O LE
I F'4 county which requ lees a permit to construct,altep Improve,demolish,or repair
q any structure prior to It.Issuance,a bo requlrn the applicant for such permit to Pc WER`D
P file a signed statement that he is licensed pursuant to the proalloss of the
3u, sin.lactora Ll ceveLaw(Chapter 9(commencing with Section 7000)o(Dlvl- pqN L E C Tt..sI'� VALUATION
slon3 oflhe Business and ProfesslonsCode)orthat bets exempt therefromand V V a V V
6 S the basis for the alleged exemption. Any violation of Section 70315 by any O IiES FS
applicant for a permit subjectsthe applicant to a civil penalty of not moa than
^ flu downer dthepr). - NEW • ALEL SQFr. STORIES TYPECONSTRUCTION
owner of the property,or my employers with wages as their Bole
rompensatioN wllldothework andthe slmctum b not intended or offered for
Osale(Sec 7044,Buelnees and Profenloru Code:The Contadoe.License Law
$ docs not apply to an owner of property who Wilda or improvo thereon,and OCC GROUP AIS.UNI IS
whodoessurhwork himsel(orthrough hisewnemployces,prbvldedthat inch
improvemcnts are not Intended or offered for sale.If,however,the Wilding or TOTAL:
improvement fs rold within oneycarofcompidiory the owner-bulderwill have
ttkr*rden of pmving that he did not build or Improve for purpose of sale.). QTY. PLUMB114CPERMIT FEE P170DZONE APN
Lf I,as owner of the property,am exclusively"
'
trading with Ia-.—
contrsctorstoconstructtheproject(See.70K Business and Professims,Code: PERMITISSUANCE,
The Contactors License law does not apply to an owner of property who
Wilda or.lmproves dumcm, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER IEA)
cg0(pdo 0)Banwd punuantm the Contractor'.Llanae Law. FEE SUMMARY
Ll l am exempt under c. B k P C for this rcaaon BACKFLOW PROTECT.DEVICE
OUTSIDE FITF�
DRAINS.FLOOR,ROOF,AREA,GOND, SANITARY Y_ N
Date / Jf RECEIPT
OR KMANIh COMPENSATION DECLARATION�e-- �.U��.�P SCHOOLTAX Y N
❑l hereby affirm that 1 have a certificate of consent to opytne,re,ora RECEIPT Y
a00,Lid,of Worken'Comperoatlanlruurance ora certlfled copythemof pec. GAS EA,SYSTEM-1 INCA OUTLETS PARK FEE Y N
3300,Lab CJ
Coliq Y GAS EA.SYSTEM-OVER 4(EA) RECEIPT Y
Cany BUILDING DIV]SION FE ES
FCertlfled copy b filed hereby
the cityed. GREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed ropy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-MRM EA 200FT Date RCCCI t#
(Thlssedion need nm be completed If the permit b forone hundred dollars
(SloWcrlero.) WATER HEATER W/VENT/ELFLTR ENERGY FEE Y N
I certi(ythat in the Ndmememof thework forwNch this permit is onsed,
I shall not employ any person In any manner coo n to become subject to the WATIA SYSTEM/TREATING
Workers'Compensallon laws o(GII(omla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date RCIxi t#
Z O NOTICE TO APPLICANT:]Lager nu king this Certlficelenf Exemption,you
Fshould become subject to the Workers'Compersatkn provisions ofthe Labor TOTAL:
W Code,you must forthwith comply with such provisiom orthb permit shall be
W > deemed revoked. BUILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affiwrm that thea b a construction lending agency for the perform- ELECTRIC FEE
O ance aftheork for which this permit is 9sued(Sec.3097,CIv.C.) TOTAL:
Iendsea Name PLUMBING FEE
LL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1mettly tNtl have read thbapplicatlonand Astethattheabove Information
IL is correct.I agree to complywlth al cityand countymclinmme and state laws PERMIT ISSUANCE FEE$PAID.
>. N relating lobul'ding construction,and hereby authors,representatives oflhb -
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD'R7 MECH. '
(We)agree to save,IndemNfy an d knp harmless the City of Cu pertinu Date Receipt#
V aga Wt liabilities,judgments,roarsand expenses which may In any way accroe AIR HANDLING UNIT ITO 10,000 CEM) SUBTOTAL:
against said City In roneequena of the granting of this permit
/1 ossa /-y/_t�fl
AIR HANDLING UNIT(OVER 10,000CIT1) CONSTRUCTION TAX
Slgrutu of Applicant/Contractor Date EXt TAUS"T fI00D(W/D[KT) CONSTRUCTION TAX PAID:
HA7A fummb MATER IALS DISCLOSURE
Will the defined
bor y
ure buildingnicipan ode, hhand lc hazardous IiFATWG UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 3,and the - Date RCCCI t#
Health and Safety Cade Section 25S32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yet i�l Na
Will the applicant orfumm building occupant use equipment or devices VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdous air contaminants as defined by the Bay Arca AU
' Quality Management District? BOILER-COMP OHP OR 100,OM BTU)
4 yrs Na
hamad lhe ealth&Safety
Coed ls Sections n05,
b5533 and 255 .I of BOILER-COMP(OVER IW,OW BTU)
the Californiaifnla health&Safety Code,&ctlone 75505,25533 and 25534.1
understand that if the building does not currently have a tenant,lhal it is my NEW RESIDENTIAL MECH. SQ.PT
responsibility to not ify,the occupant of the requirements wh lch must be met
prior to lasuence of a Certificate of Occupancy. '
Owner or authorised agent Date TOTAL: I ISSUEDWY.
OFFICE COPY
CUPERTINO ROUNDTP•EE
ARCHITECTURAL CONTROL IMPROVEMENT APPLICATION FORM
• TO THE ARCHITECTURAL CONTROL COMMITTEE:
Owner(s) : Thomas Watson Date: November 1, 1990
Property Address: 21105 Whito Fir Court
Owner Address (if different) : 8117 Presidio Drive - Cupertino, CA 95014
�
Owner Phone: Home:d77.5_�?-T 7 L L Work:
Description of Improvement Applying For:
_72,10 ./,2-) /JW01V7 /G/CHT-s
Color(s): ._ P,0/V7_
Location(s) : P2h7772 - f UE? -1)11,11VI"rr AI.2,f-A
Dimensions: -A 2 x
Construction Materials:
Contractor:
'A scale drawing of all improvements, showing location and dimensions, must be sub-
mitted with this application and attached to application.
• Affidavit: I/We are the current owners of the above described property for which this
application is made. I/We understand the restrictions contained in the Declaration
of Covenants, Conditions and Restrictions and agree to abide by the decision of the
Architectural Control Committee on this application, including all conditions which
may be put on approval . I/We agree to be solely responsible for the events creat-
ing the improvements, maintaining the improvements in good condition, and any
encroachment this improvement may make on adjoining unit owners' property and/or
common elements areas. I/We are responsible for obtaining all permits that may be
required, complying with any building codes or regulations that apply, and will re-
imburse Cupertino Roundtree for any liability or costs arising because of this
improvement. I/We understand that final approval is conditional on an inspection of
the completed improvement for compliance with the description in this application
and the conditions of approval . If the improvement does not meet the final inspection
criteria, I/We, at our sole expense; will restore the property to its condition before
work began on improvement. If necessary for repair and maintenance of the structures
andiareas, I/We will be solely responsible for removing and replacing the improvement
to make way for such repairs and maintenance. I/We will notify successive owner(s)
of this property of this unique improvement, the conditions of approval , that
Cupertino Roundtree assumes no responsibility for this improvement, and of their
duty to likewise notify further successive owner(s).
All Owners of Property Must Sign Below:
Date: / ov )_X4 tsSigned':-. moi-Li ce (jaYc Printed Name: 7. D. WA ,50 r/
Date: Signed: Printed Name:
• ARCHITECTURAL CONTROL COMMITTEE USE ONLY Date Application Received: a U Received by: rr•
Date Approved: Date Disapproved:
White Copy - Committee Canary Copy - Unit Owner Pink Copy - Management Co.
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