21869 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pn)'ect Identification - PERMIT NO.
Building Addrem: ,� i3-e 21869
�wn—ererone: t A
CITY OF CUPERTINO-BUILDING DIVISION -L •Z(�--(, '
Comm or•sName: u.No: APPLICATION If PERMIT
R..e BUILDING-ELECTRICAI.PLUMBINC-MECHAMCAL CATEGORY CONCOL
Architect/Engineer: Lie.No:
K %m w e 44 - X I 1 - ' ' V BUILDINGPERMIT,INFO
UJI . Fsa6+ Q - I;,l . 1£LECTRIC!PERMIT TEE '
Adder. \ L •.N2t PERMITISSUANCE .�
LICENSED CONTRACTOR'S DECLARATIONYl-
- -
I hereby affirm that I am licensed under provisions of Chapwr9(comrrtere. APPLIANCESRESIDENTAL JOB DESCRIPTION
Ing wlthSSctlon 7000).!DiA.i.3 o(the Buslnessand Professions Code,and my - i 4'N r� N. I)
License Is In fue and effect PANELS A VQ�Z�„) l_.P IST\ "J
License ClapLlc.M LQ kZ�.
Dateli(�A:n S.LCmumencUP TO 200
-
ARCHITECTSDECLARATION 701-1000AMPS
A iSQ.FT.FLOOR AREA - $/SQ.FF.
•AZO Iundstauted my play.haB beused as Public remrds. OVERI000 , j1 j tv
d v
Licensed Professiol SIGNSELECTRI 1- '
6N OWNER-BUILDER DECLARATIONSI+ECIALCBtCN
7p eG m am exempt hereby affirthat I aexempt from the Contractor's Llanae Law for the
followingreaaon.(Section 7MIS,Business and Professions Code:Any city or
cm .Np "S
O � nlywhichrequiresapermitwcovtmcgalter,improve,'demolbM1,orrepalr ' TIMP'METEROROA .
�4 anystrumme pectin Its beance,alsorequiresthe applicantfor such permit to POWER DEVICES file a etem
igned statement that he b hcxo a pursuant m the provbions of the _ -
3w Contractor'sLicense lAw(Chapter9(commencing with Section 70M)of Divi- ' VALUATION
I-n SWIMMING POOL ELECTRIC
O the basis fo the alleged
dexemption.0 Any
violation f Seem therefrom and
the bash for the alleged exemption. Any violation of Section 70315 by any0/�
« aPPllcantfora permit subjectstheapplicantt.advll pevltyana morethan V OUILETSSWI1CFffSFIXTI/RES
five hundred dollars($50O), NEW RESIDENTIAL E.ECTR SQ.FT. v5Toftms TYPO CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sok
�Za compensatlon,will Bothe work and the stmdure is tat intended or offered for
0, sale(sec.7044,Business and Profesalov Code:The Contractors License Law
$ does not apply to an owner of property who build.or Improves them.n,and - OCC.GROUP RFS.UNITS
who does such work himself or through hlsown employees,provided that such 1 - ,
Improvements arc not Intended or offered for sale.If,however,the W 0ding or , TOTAL: L
- Improvementlssoldwithinoneyearof=ompletion,theowner-buRderwill have \
it�}nrrden of pmving that he did not build or Improve for purpose ofsakJ. QTY: jay] �,PLUMBING-RERMIT,��It r' I s FE$•? ,W,ppD ZOMi APN ,
t I,a.owner of the property,am exclusively conlrading wltM1 Ilcenaed
contractors to mmtmd the project(Sec.70K Businessand ProfeaPERMIT ISSUANCElons Code: 1
The Contractor's License Law does tiro apply to an owner of property who ALTQi-DRAIN&VEN-WATER(EA) -
Wilda or Improves thereon,and who contracts roc such pts(ujecwith a \
�aaor(s)Hmnwd pursuant to the Commuter's License Law. ,;FEE SUMMARY' 1
I am exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE
DRAINSFLOORROOF,AREA,CO SANITARY Y N
Owner Date RECE N If
ca
WORKMAN COMPENSATION DECLARATION �ryKfa SC1i0N
0L TAX Y
❑1 hereby affirm that I have a cedlRte of consent to'.elf-Insure,or a IV('NRFS PER TRAP xL!' RECEIPT N
certlfl=ateofW.rk WCompevadonlvuranmoramrtlfW mpythiumf(Sec. 11 CAS EA.SYBTEM-11NC.60UTLEI5 z PARK FEE Y N
3800,Lab CJ l ,
Palry N r - — RECEIPT N
CAS EA.SYSTEM-OVER 4(EA)
Cam any - B UILDING DI VI SION FB ES
Certified copy is Beed with
the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy b(Tied with the city inspection division.� � N�� '
'CERTIFICATE OF EXEM PFION FROM WOR K ERS' GREASEIRAP PAID .J 11
COMPENSATION INSURANCE . SEWFR-SANITARY-STORM EA.700FT. Date Recei tM eco
(Fhl..ectl.n need not be complcted if the permit It;for one hundred dollars
(8100)otifyth
I .
re )
rt IceIn the pedMbWATER HEATER W/VENT/
performance work for permit
Wood, ELECTR ENERGY FEE Y N_
I shall not employ any person in any runner an as to become subject to the WATER SYSTEM/TREATING
Workers Compensation lawa.f CallfornO.Date PAID
O Z Applicant NNEWRESIDENTIAL PINS. SQ.FT. Dale Refer to
Z O NOTICE TO APPLICATIf,after nuking this Certiicateof Ezemptian,you
should become subject to the Workera Compevatfon provisions of the Labor TOTAL:
CC W Code,you must forthwith comply with such provisima orthis permit shallbe BUILDING
W ) deemed revoked.CONSTRUCTION LENDING AGENCY _ SEISMIC FEE G
tl Z Ihereby affirm that there is acovtrvctlon lendingagency forte perform- TOTAL: _�eTtc-l� ELECTRIC FEE
aero w the work for which this permit is Issued(Sec.3097,Civ.C.) ttJK.v \
(,) O lender:N. - PLUMBING FEE
IL F Lmdeex Add. QTY. MECHANICAL'PERMI FEE ' MECHANICAL FEE
O W k
1certifythat l have read thisappllcatlonand amtethatthesbove Information -
Is coned, agree to comply with all dtyand county ordinances and slate laws PERMITISSUANCE 4� FEES PAID:
>_ C W relating to building constmctlon,and hereby authorize representative.of this 1 (] _uL_
F Z city to enter upon the abovo-mentloned property for Inspection purposes. ` ALTEROR'ADD'PD H. -1\[�
-(We)agree to save,Indemnify an d keep harmless the City of Cu pen Ino _Date.' Receipttt
V ags me liabilities,judgments,me%and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
-� g ivt Id City In mty
nsu the granting of this permit.
NR HANDLING UNIT(OVER 10,000C 1 CONSTRUCTION TAX
SIgnanumoor ppllan Contractor Date EXHkUSTHOOD CW/DUCT) CONSTRUCTION TAX PAID: .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle tiardous HFATINGUMT(TO100,000BTU) Date Reeel till
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the --
Health and Safety Code�+.-S�ection 75537(a)?- HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea , u No
Will the applicant or future buildlegoccupant use equipment or devicesVEN`I1LATlONFAN(SINGLE RESID) \ ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District? 0 BOILER-COMP QHPOR 100,0(0 BTU)
4 Yea rd IIII�FF1R
have read the haza mus materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU)
the Califmu.Id=alth&Safety Code,Sections 75505,25533 and 75534, 1 �tq1 5 111q�
understand that lithe building does not currently have a tenant,that it is MAY 4 my NEW RESIDENTIAL MECH. SQ.Fr 1'+C
responsibility to rally the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy. - j
:. (i( (Of
Owner or authorized agent - Date
TOTAL: ISSUED BY: UCr.4_
v
OFFICE COPY