21908APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ea Identification
"°°ding Address:
PERMIT NO.
21908
o
ner• arm . Gaaeoey,u one:
w
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
ontnctor'a Name;/iRST 6Ee# /e#.eA#C s&.ruaeerfae.Nre
CATEGORY
CONTROL#
i 1%
BUILDINGELECTWCALPLUMBING-MECHAMCAL
Architect/Engineer. a Lic. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
C
./�
Address: 67 M% S
j�i� ❑
LTJ
PERMITISSUANCE IAa
LICENSED CONTRACTOR'S OCCLARATION
Ihereby affirm that l are Hemsed under provisions of Chapter 9(comment.
on3°fthe Busimxeand Pro(esstonsCode, and my
inense11.fon force and
liana is fn full force and effect.
effect.
APPLIANCES -RESIDENTIAL
IOBDFSCRETT N 1
nz)
�(ftj�CVVJ
PANWS
Lignac Class ic.#
Date Contractor
701-1OWAMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
OVER 1000 AMPS
SQ. FT. FLOOR AREA
f/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MISC
BUILDER DECLARATION
OWNERARA
I hereby atlirm te
I am exempt from the Q°rB License law for the
e—
TEARMETERORPOLEINST.
following mason. (Section 7031.5, Business and Professions Code: Any city or
cou sy, which requires a permit to construct, alter, improve, demolish, or repair
anystructure prlorto Its issuance, also requiresthe applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING IDOL ELECTRIC
0 OUTLETSSWITCHESFIXTURES
Contractor'. License Taw (Chapter 9 (commencing with Section 7000) of Dlvi-
sion 3 of the Businessand Profeai°ns Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 70313 by any
applicant for. pemtit subjeet thea pplicanuo. civil penalty of not more than
VALUATION
five hundred dollars(&500).
I]1, as owner of the property, or my employee with wages as their sok
NEWRERDENTIALELECTR SQFf.
STORIES
TYPECONSTRUCTION
compensation, will do the work and the structure Is not Intended or offered for
sale (Sec 7064, Business and Prolesslons Code: The Contractors License Law
�'I �st
TOTAL: L ,m
does not apply to an owner of property who Wilde or improve thereon, and
w
whodomsuchwork himatforthrgh hisownemployees, provided that such
improvements are not intended muttered forsale. If, however, thebullding or
OCC.CROIIP
RFS. ONUS
improvement issold within omyearofcompl0iogtheowner-W Oderwill have
thtt_turdenof proving that he did na build or Improve for purpose ofsale.).
LJ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business+and Professions Code:
QTY. PLUMBING PERMIT FEE
FLODDWNE
APN
PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who
Wilde or Improve thereon, and who contracts for such ptojem with a
op4actor(s) Hernxd pursuant to the Contractor's License Law.
LJ 1 am exempt under Sec 0 & P C for this rcaann
ALTER -DRAIN & VENT -WATER (EN ^2 .cw
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECE7I'T#
Owner Date
WORKMAN COMPENSATION DECLARATION
MI hereby affirm that I have a certificate of consent to .11 -insure, ora
certificateo11N.,lu sCompensation Insurance ora artiftedcopythereof(Sec.
38001Tab C.I
FIXTURES PER TRAP -2, CZ)
SCHOOL TAX Y_ N_
RECEIPT #
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FFP YN
RECETT #
Policy#
Com anv S'/S9f� -
GAS. F.A. SYSTEM -OVER 4 (FA)
BUILDING DIVISION FEES
crtlficdcopybhercbyfurnlshed.
Certified copy b filed with the city Inspection division.
GRFASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
;-sem (
SEWER -SANITARY -STORM EA p0Fr.
COMPENSATION INSURANCE
CThissection need notbe completed If the permit is forone hundred dollars
Date Rettll t#
a^
.5a-`'!
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
(f1 W)olf8s')
1 artily that In the performance of the work forwMch this pemdt Is Weed,
WATER SYSTEM/TREATING
I shall not employ any person In any manner soas to become subject to the
Wnrk,es Cumpenaatiunlawsuf CaIifornla. Date
PAID
NEWREMDENTIALPLMEL SQ.FT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recei t#
TOTAL:
BUILDING FEE
Cole, you must forthwith comply with such provisions orchis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
� O
I hembyaffirmthat there is a construction lending agency for the perform,
ance of the work for which this permit b issued (Sec. 3097, Civ. C.)
Lender'. Nam
fenders Address
TOTAL: �(',
ELECTRIC FEE
PLUMBING FEE
.00
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
1 cedifythat I have read thbappHcatfonand statethat theabove Information
brrect. I agrxto comply with all city and county ordinance and state laws
co
PERMIT ISSUANCE
FEES PAID:
mlating to building construction, and hereby suthorix representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We)�re a to jade, haderreffycess and keep harmlessharmlessthe City of Cupertlrw
ywayae
.8. o"11a0flltks, judgmentsuscert , rad expenses which may in anccru
agal t dCity in cunseque p the nungnnhmperm' It. /
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (1010,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000 CRT)
CONSTRUCFIONTAX
.Ignatvru o(Appllant/Con_/. r Date
D(HA715'T HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAIARDOUSMATERIALSD CLOSURE
Will the applicant or future building occupant store or handle hazardous
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ifealth and Safety Code Section 75532(a)?
Yes V_� No
Will the applicant orfuture building occupant use equipment or devices
which emit harardous atr contaminants as defined by the Bay Area Air
Quality Management District?
Ye Na
have read the had ous materia'. requlrcmenb under Chapter 6.95 of
HEATING UNIT (OVER Iffy" BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
!f
CC''
IIIA
I„f'1
BOILER -COMP OHP OR 100,000 RTD)
ROLLER-COMP(OVER 10D,000 BTU)
the Glife mIs Health & Safety Code, Sections 75505, 75533 and 25534.1
understand that if the building does not currently have a tenant, that R b my
tj,1j1
1,9,91
NEW RESIDENTIAL M[CH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior to notia not of a Certificate of Occu pa nay.
Rnrg�ry##��
V>S lY7d !'Ffse.(t
ISSUED BY: FT1f ,f
Owner or authoriced agent Date
TOTAL:
OFFICE COPY