21464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addmas: 21464
d S 2 Le �r4� c nj K e
wners a 4 �pone: A p q
AJ06L-A; CITY OF CUPERTINO-BUILDING DIVISION �d
C.vuato N Ic.Ni: APPLICATION / PERMIT —
BUILDING-ELECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/EnEtc.No:
.P/ QTY' ELECTRIC PERMIT FEE 'BUILDING PERMIT INFO
Address /7 6 NQN F� ;ER—TISSUANCE 1.21 0
LICENSED CONTRACTOR'S DECLARATION
I herebyalfirenthat l am licensed under provislonsof Chapter9(common APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section700D)cf Dlvision3ofthe Businessand ProfessionsCods,and my
license is in full force and effect. PANELS y/�.
License Clan Conti �} / � PD �e —
Date Contractor �N [ 201.1000 AMPS
ARCHITECTS DECLARATI
Cd)]. I understand my plana aha!be used as public records OVER]WO AMPS SQ.FT.FLOOR EA 5/SQ.FT.
O
�j Licensed Professional _ SIGNS ELECTRICAL
6 m OWNER-BUILDER DECLARATION
SITFCIALCTRCUIT/MISE
owing r ssum.(Section
that l am 31.5,B from the d Profctoons Code:sms,Law for the
O7.9F� fo0owingreasoq requires
permil$Buslnen and Professions Code:h,Any cityormp it TpA(p.SIFTER OR POLE INST. -
coantywhich requires a bouan tomnsleuct,alter,quirrathe applicant provq demolish,or mit to
SU znystmdurepdortmttshat he is alanard pursuantttheenvisionsorsuch of permit to
POWER DEVICES
O file a signed statement that he V 11«nsed pursuant to the provblons of the
µtr, Contractor'.License Law(Chapter 9(commencing with Section 7")of Divi- SWIMMING POOL ELECTRIC VALUATION
'101 sion3of the Business and Professions,Code)orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLGTSSWITCHCSEU(TUItES
00 applicant for a permit subjects the applicant to a civil penalty of net more i ban
five hundred dollars($SM.
las owner of the property, NEW RESIDENTIAL ELECTR SQFT. TYPE CONSIRIICTION'"-
?¢ p ork,a ser my employees with wages r there sole
compensatioe,wBldo the work andthe structure k not ntractintended or offered for
sale(Sec.7044,Business and ProcessionsCode:The Contractofa License law� A$� does not apply to an owner of property who builds or improves thereon,and OCGGROUP RFS.UNITS
whodoessuch work him Iforthrough hlsown employees,provided thatsuch
Improvements are na intended oroffered for sale.ILhovevegthebuildingor TOTAL
I : ♦
improvement V sold withinoncyearofeompltioM the owner-builderwill have
d"iden of proving that he did not build or improve for purpose of sale). QTY. PLUMBING.PERMT FEE ` APN
U 1,as owner of the property,am exclusively contracting with licensed
men"c Tea to construct the project(Sec.7014,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who
Wilds or improves therron, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
cc,a(Tact«(s)licensed pursuant to the Comrador's License Law. BACK FLOW PROTECT.DEVICE. - FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. RY Y_ N_
Owner Date RECEITN .
WORKMAN COMPENSATION DECLARATION FIXTURES.�.�T SCHOOL TAX Y N
711 hereby affirm that I have a certlRrate of consent to self-Insure,ora RECEIPT M
certificate of Workers'Compsmatlmn Insurance or a certified copy thereof(See. GAS EA.SY91EM-1 INCAOUTLE15 PARKFEE Y N
3800,Lab C.)
Polkya RECEIPT N
GAS.F.A.SYSTEM-OVER d(EA) BUILDING DIVISION*FEES
m ray
Certified copy is herebyfurnished.cid. GREASE/INDUSRL WASTE INTERCEPTOR, PLANCHECKFEE
' Certlled ropy b,filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAIT t PAID
COMPENSATION INSURANCE - SEWER-SAhTCARY-STORM FA.200FP. - Date RCCCI t#
HBlssedion need net W completed if the permit is forom hundred dollars
(51M cless.) WATER FIFATEIi w/vENT/n.ECTR ENERGY FEE Y_ N_
I certify that In the performance of the work for which this permit is Word,
I shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Laws of Califomla.Date PAID
0Z Applicant NEW R[SIDLNTIAL PLMB. SQFT. Date Recel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subject to the Workers Compereatlon provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall W ILDING FEE
LU j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl Ihereby affirmthat there is a construction lending agency for the perform TOTAL: ELECTRIC FEE Q
7 Z anceofthe work forwhkh this permit b bunied(See.3097,Clv.Q
(� O Lenders Nanr PLUMBING PEE
LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
IrenJtl
ythatl have read thisapplicaon and stalethatthe above Information
O W
C iscorrect.I agree to comply with all cttyand county ordinances and statelaws PERMTTLSSUANCE FEES PAID. -
relating to building coretrutlon,and hereby authorize representatives of this
N city to enter upon the abovo-rnsriond property for Inspection purposes. ALTERORADDTOMECH.
Z Date Receipt#
'(We)agree ve,indemnity an d keep harmless City of Cupertino
V against Iia s,' dgmen Band expenses which may in any /.y. a AIRHANDLINGUNITOOlQ000CFM) SUBTOTAL:
agzl Cityi co ucn«o[the grant:;of this perm it ' a MR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
odea CONSTRUCTION TAX PAID:
Signature of Applicent/ ator Date IXFUUSTHOOD(W/D[K:T)
HA7ARDOU ATERIALSDISCLOS RE -
Willthea llo est or tutu -Odin Deas ant store.rhandleh.sicut, HEATINGUNITOO 100,0001IM
PP 8 P Date Recti t#
materiae as de(ind by theC rtino Municipal Code,Chapter 9.tZ and the
4lcalth and Safety Cd:No
Ion 255 a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant oure tiding occupant use equipment ordevies VENTILATION FAN(SINGLE RE5ID) ISSUANCE DATE
which emit haeardous minants as defined by the Bay Area Air GA
QuuAity Management 7 BOILER-COMP DIIP OR I W."BM
�- 4haveereadthehazsteriabrequimm n!sunder Chapter6.95of BOILER-COMP(OVERIDQ0WEEFU) fsI (/ .r n
the California Health&Safety Code,Sections 25505,75533 and 25534.I 01 1 ✓ 1990
understand that' does not currently haveatenanL that it6my NEW RESIDENTIAL MECdi. FQ.FT.
responsibilit I toss ant of the requirements which must W met
Pit. roof rtifka Ocmpancy. CRY Mlsa of Ca
sa�aag
Owner or eauuthodnd agent / NOTAL: ISSUEDBY:.Iv
OFFICE COPY