21591 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen Identification 7 PII?MITN'O.
Building Address: 215 91
os- A � I
rs ams: one:
CITY OF CUPERTINO�BUILDING DIVISION
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tractor's Name: Lo N. APPLICATION / PERMIT
to. o AnLP�} gj Sit-=Trej I - QBUrIDINGELECTRICAI IV MBINGMECHICA
ANL CARYZ CONTROL Y/ -7 ` ^
Archttect/Engineer. IJr.No V JiL/
CV Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
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Addresti w V PptMl'[ISELIANCE
LICENSED CONTRAC"ORS DECLARATION
IherebyaBirmtlullam Brmsedundnrpm Wb o(Chapler9(a yen APPLIANCES JOB ON
Ingwith Stolon 700D)of Dldslan3ofthe BuMn and Pmfodoru Code,and my
have b In fullfora and effect. PANETS
LlmrueCh® LR.6
Date ��I CoMranorUP TO 2DO ANTS
���/f��AR-CHITECTB DE LARATI
02. Iunderstand my plan shad]be used n public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O SIGNSELECIRICAL
Cloyed Prdubvl -
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
zE, 3 IherebyafRrmthat lamexempt fromthe Contractorb Clave Lawforthe
qoo following reason. 70715,Busluess.nd Pmfembro Code:Anycityor
FF'� cwntywhich requtrn•pemattocovtruct,almr.lmptomdemalbh,orrepalr TFMP.MEIl]t ORPOLE INSf.
q''� any.imcturc prbrto lb bsuave,abo requBntheappBant(orwch pematto POWER DEVICES
P Ne a signed rnlearent that he b Iloerued pursuant to the proWbn of the
3� Contractor:Licenee Law(Chapter9(commencng with Section 7000)of Div SWIMMING POOL,IT.ECIFIC VALUATION C3
F, O sbn3ofthe Buelnneand Profenbv Cade)orthmhebexempttherrlrom..d
Sn tk bash for the alleged eaempbn. My violation of Section 7m15 by any OUTLEISSWITC "1 a
aPPBcandred dollars
otheapplicwtoadvll pevlty of not morcthan /L D
E ❑use hundred ddlvshe p0). NEW RESIDENTIAL
$FI. STORIES TYPE CONSTRUCTION
�n
F11,as lou willer ft the work and nryeucture nwtlh wagnuthered fo
�7 mm(S,-70 ,wWdotheworkandthesCccie bwomoaded aroff Law
p sale(Sec706{,Busineaami Pmfesebv Code:TLeorimpo esMame Law Lrikv
r'f3 dm stop,lytoan h.rkh lf.,th Sin M,..ul pl ym,pv Wt dreon,and
a-s^ whodoneuchwork hlmve8ortheough hbownemployen,prwdedttitsud' V. OCC.GROUP . RES.UNITSImpmamernsartunintended orokered foraale.l(however,lhebuildingm TOTAL:
Improvement baald within oreye�ro(mmplelbr�lheowner-bullderwlll have
ld
tl arden of proving that he did not build or Improve fee purpose of sale.). QTy, PL BI ERMIT FEE
L as owner of the property,am exclusively tmLLracting with Ilancd FLOOD ZONE APN
LJ
mntnRons to mnrmct the project(Sm 7066,Busbee and Praferbv Cede PIEFITTOMAkNCE
The Contractor's License Law don not apply to an owner of property who
bunds or Imp.thereon, and who mrdracts for such pipjecb with • ALTER-VIAIN&VEM- TEA
rlpq-ctor(ni licensed poravnt to the Contractor.License Law. s wI'itorEcr.D 4 FEE SUMMARY
U 1 am exempt under Sec B &P C for this reason
DRAINS FTDOR,ROD ND. SANITARY Y N
O Owner Done RECEIPTFxRECEIPTj
I
WORKMAN COMPENSATION DECLARATION
❑1 hereby aIftrm that I have a certificate of ameent to self-Insure,or FO(TuRu&PFR TRAP SC7100L TAX Y N
aklfiate of Workers'Compensation Insurance a a certified copy them((See. RECEA7 if
3500,LbC3 GA&FA.SYSITIM-IlNCVOUjE2PARK FEE Y— N
Pdlcy I RE{EM.
Com n GAS F.A.SYSTEM-0VER4(FA BUILDING DIVISIONFEES
Ned mpybhereby harnbhN. CREASE/INDUSIRL WASTE INTERCEPTOR P NCHECK FL•E • ' '
CekBled copy is filed with the aiy Ivpeetbn divialon.
CERTIFICATE OF EXEMMON FROM WORKERS GREASE TRV' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 7WFT. Date Remi t#
(fhb aedlon need nor be completed B the,scoot la froom hundred dollen
(f100)afy that WATER HEATER W/VENT/ori-rR ENERGY FEE Y N /♦
laonytinnily anyhe person iaorthewar so
to ech
Wapemdlbbathe
1 orkhalnot employ any perm b any runner at u m beaorrc subject to the WATERSYSTEM/TREATING
weekm�earnPertutlan Lawaor e.luanla. Date PAID
-
Z
ZApplicant NEWRF9DINDALPUIe. SQF7. Date Recei t#
O NOTICE TO APPLICANT:If,after malang this Certificate of Exemption,you
should become subject to the Worker'CompevaUon provbbv of the Labor TOTAL:
N Cade,you most forthwith comply with such imwislov or this permit shall be Q
> deemed revoked. 13UILDING FEE
W
W C CONSTRUCTION LENDWO AGFTCY SEISMIC FEE
CL I hereby a(flrm that there is a construction lending agency for the pekomn, ELECTRIC FEE
Z ane o/The work for whkhthb prr'dbblued 6ec 3097,CW.CJ TOTAL
V O fenders Name PLUMBING FEE
LL 1— Larder:Adams QTY. MECHANICAL PERMIT FE
O W lakllythatl love read this applfcatbM r
naarctluttheabovelnfarmNon MECHANICAL FEE
l
(1
is correct. to comply with all city and county ordinances and late laws PERMIT ISSUANCE FEES PAID.
} relating to bending camorectler,and herebyauthorrne
fm repentatNof this
Cr
F Cr city to enter upon line above-mentioned property fa inspection Purpose. ALTER OR ADD TO MEAT.
(We)agree to rove,Indemnify an d keep harmiea the City of Cu pekln, Date Remi t#
V aga hast liabilities,jrd gmenb,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM[) SUBTOTAL:
agal dCity In aequeran aftk grantbg oftMs pemdL AIRITANDUNG UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signature of Appilant/Contrxtar Daust
EXrIAIhT HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant Blore or haMk hazardous HEATING UNIT CTO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and SafetyCade Section 23532(a)7 FMATING UNIT(OVER 100,DOO BTT, TOTAL:
❑ Ya No
WWthe appB mr Nrebuildingocupnt..egryip.rctordeviny VFN'DL,I7TON FAN(SINGLE RE9D) N�('F7'T
ISS1 ATE
which emit tazardous air cntaminaMs as defined by the Bay Area Mr 1�C �[
Quality Management District? BOILER-COMP OEIP OR 100,000 BTM
❑ Yn I�I No R
. Ihavemadthehaaa ousmHekabrequlremenb under Clupler G95o( BOILGILNMP(OVEi]00.000 BTU) JAM
7 �y.E
the Calfamia HeaHh&Safety Code,Sectio;2505,2S573 and 25536.1 ! M 6 wv
undmtaw that if the WDding don rot mrrcntly tuveatenant that itbmy NEW RESIDENTIAL MEIN. SQ.FT
mspomlbdity to notify the occupant of the requbements which most tae mrt `__'• _
prior to bwarur of a Ceklficete of Occupanry. ',^F'tF�aNI'll�fl
Owner ser authokred ageot Date ISSIIEU BY: `
TOTAL:
OFFICE COPY