21094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentmcationPot. TNO.
Bmla�,�Adah,: �� 21094
weer //``CC//jj. IAL UAIL
72 CITY OF CUPERTINO-BUILDING DIVISION
CoMMA° '�" Na APPLICATION / PERMIT
MM /
�' ��� BUILDINGELFCTRICALPLl7MBING-MFLHAMCAL CATEGORY CONTROLII
Archhen/Engineer. LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'$DECLARATION
I hereby af(innthatlam licensed under pravblons of Chapter9(mmmmc- APPLIANCESRESfDENTIAl JOB DFSCREPTIION
ingwlth5ed u n 7000)anDivlslon3ofN<Bu,lnessand PmfnslonaCode,and my
licen,c is In full jjjjjjggqqqqrtx and effttt. L Sz PANELS s... .
LlmnseClle N _�ll
Date--lltett�l ConlraRor tE E-.CI,ti++/-OFi /
ARCHITECTS IARATI N 201LIE-1000 AMT'S
077 I understand my plans shall he used a public records. OVFRIIk)OAMPS SQ.FI.FLOOR AREA 5/SQ.Fr.
k dl U Llccnxd Prulcsebnal SIGNS ELECTRICAL
<<�6 OWNER-RUILDER DECLARATION SPECIALCIRCUIT/MISC '
Iherebyases that l am exempt from the Contractor's License law for the
'Z O loeowing rtason.(Semon 70315,B.Iftwus and Profession,Code:Any city or
O G Hons TEMP.MLTTR OR['OLE
F�3 county ciumwhicprimrospiWits permitcommreciiirmcL e.thften, apmvSdemolbh,armitto repair R
any atsi ned pdorroltshat he It aLw rted pursuant
sueappemHonuions of permitto POWER DEVICES %J IVI
C I.O file a signed statement that he b r9(o.rd pursuant it the pcoWbra the
Confront/s Llcensel�w(CWpter9(comrrcn<ing with Benton 7000).f Dlvl- SWAIMING F.ECfRI o VALUATION
0 e basis fo the alleged
le d Pmfemion. Any violation
M1e f Seem 7MIS by any
H
_ the Want for the alleged exemption.applicant
Any violation of nattySectino room
by any
<`
applicant lots permittubjenttheapplkanuoa civil penalty of not nnrc Urn--0UTLETS-SV0FCHESFIXTURFq
five hundred dollars WOO).
I,as owner of the m NEW R FNTIALELECTR SQFT. STORIES TYPECONSTRUCTION'
property,or with theirsole
�7a soic&,7044compinsationi,willdolhoworltandthes Coduttbn Contractors
orcense Lfor
❑ diesnot apply to strowandf property
Code The orimpomes Lkmon Lw
$ don not applymsn owner ofpmperty who builds orimprwnlhermn,and
c,t.. whodoessuch work hi.1forthrmgh hlsownemployees,provided thatsucM1 OCG GROUT' RFS.UNITS
impmvemcnts am nor Intended orofferea for•ale.If,however,the building or TOTAL:
Improvement b sold within oneyearofcompldbn,the owner-builder will have
the rdenofpmvtng that he did not wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
1,at owner tr the property, Se exclusively Business
ess and
with Brewed PERMIT ISSUANCE
conThe Contractor's
ct construct the pmjo es notc.apply
Business and Professions Code:
The Comm�orb set the Law and not apply tct an owner d properly who ALTER-DRAIN 4 VENT-WATER IRA)
.Bola or Improve[Ferro., and who Cc introns for such p-I with a
L�tTact.eemte underil Snt to me ContractoYs Litter Law- BACK FLOW PROTECT.DEVICE FEESUMMARY
L�I am exempt under Sec B&P C for thin mason
O
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y— N Owner Date RECEIPT=
,��/ WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP 5O100L'FAX Y_ N
Aifi hereby ora nthat I have o aenBiare ofctnuem amnifi m spytheum,ora RECEIPT N
MO,Ub ofWorkers'Campensatlon lnsuranre ora ttnllled ropy themof(Sec. GASEA.SYSTEM-IINCAOUTLETS PARK FEE Y_ N_
3800,Iib C.) /, /� fi �r
PaliryN C�Y-cUC�/,�Z-ls 3��C..� RECEIPT N
Cam env f4PJ1A'J c r CA EA.SYSfQA-OVERA(FA) BUILDING DIVISION FEES
Cb
copy In he by furnished.
E;a§Sdified ropy Is filed with the city Inspection division. GREASE/INDUSTRLWASMIN RCEPTOR PLANCHECK FEE
CERTIFCATEOF IX6MPTION FROM WORKERS' P=TFRH:EATMWAFNT/ELECTR
PAID
COMPENSATION INSURANCE Y. EA pOFT. Date Recd ted
(ihissenion need not W completed if the permit b forone hundrod dollars
te100)rtifyt.) ELTR ENERGYFEE YN
Illout thato the person Inofthe work st, whichthispermitcissued,1 Works not employ any person In any manner m a to become subjeci to liar. TRFATINC;Workerv'Compensatlonhove of Glllomla.Dam PAID
cant
Z Q NOTICE TO APPLICANT-.If,after making this Certifiate of Exemption,you L PLMB. QFp. Date Recef I#
should become subject to the Warlan'Compemadon pmvbW.of the Labor TOTAL:
CC N Coda you must forthwith comply with such provisions orthis permit shall be
j deemed revoked. BUILDING FEE.
LU
p CONSTRUCTION LENUING AGENCY SEISMIC FEE
I hereby alarm that them b a construction lending agency for the perform ELECTRIC FEE
Z tore of the work for which this permit u Issued&c.3097,Civ.C.) TOTAL:
U O Lendeb N.me PLUMBING FEE
LL I<.der.Aadrty QTY. MECHANICAL PERMIT FEE MECHANICAL FEE Oa
U Iredlfythatl have mad thbappeatianand nate that the above Information
O1 bcorrect.I egree to comply with all city and county ordinances and gate laws PERMITISSUANCE �Z, OD FEES PAID:
W relating tobuildl.g covtrucE.n,a^d herebyauthodm-,te tativn ofthls -
Z otytoenteru theabovcmenBoned properly for impectlan purposes. ALTFRORADDTOMECH.
fwd agtt save,Indemnity an d keep harmletethe City of Cupediro Date Receipt#
O againstllabll a pd goner dSep nx whlchmaylna ywa ammo AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against sold it�d tfthagrtnting dthb pe R.
AIR HANDLING IRJIT(OVER t0,000CEM) CONSTRUCTION TAX
Bignatu on of AppBa.t/Contractor L Date FXHAUSTHOOD(W/DICT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha,cardous HEATING UNIT QO IO0,000 BTI) Date Recel t#
material a defined by ted Cupertino Munldpal Coda Chapter 9.1 Z and the + I4
Healthand SafetyCodc Senion75537(a)7 t HATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yet r!No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$LJ�IYICE DATE
which emit l avrdou,air contaminants.,defined by the Bay Arca Air P���,�jDn6J
Quality Management DisWtl7 BOILER-COMP OEIPOR 100,000 BTU)
❑Yea 1�No PI
1'
IWit.,nU FeF r�ou,mWc,a equiremcntsunder Chapter 4. I of BOILER-COMP(OVER IW,000BTU) P' Oy 1 1990
toeerstan tHealthkSafety Code,Senlon75505,ve a tand75534. I
undersmndthatnotify
of the.ngdoet oft ereq.im aveaemhL that it�myout NEW RESIDENTIAL M1fECFi. SQ.FT. .,
responsibility prior tuto notifytheoate of ofthercquircrrrntt which must be rrct Cd.v nf(sf
prior to issuance oft Cedlllata of Occupancy. V �M"ro
Ownerorauthodred agent Date �T�
TOTAL: tV U ISSUED BY:
OFFICE COPY