21811 "PPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlflaatimi PERMIT NO.
Building Adders: 21811
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xrivnera ame: !/ ®f: Nt'1 LltACt�I,U unlMtt l/1L WA 11,
- ITY OF CUPERTINO-BUILDING DIVISION .— r/
-! Coniract or'a Name: i.Ty ���� 7-Lm.NO. 'APPLICATION / PERMIT G"�ru�q_" '
Architect/Engineer. Ca•�-L•b�'/ L Lk.No: BUrLDINGELECTRICA6 PLUMBING-MTGHAMCAL CATEGORY CO•-•r•,-••-�
`! J 9 7fD0
—�3, •�QTi'I '•, ELECT2IC PERMIT''• t iO FEG In t `l BUILDING P,ERI'LUMB FO
!,�_( _ / T ot.w et,u.t t•t.uMtt ntr�it JI
Address. PERbIITISSUANCE• ,-•s[� 1\71 ❑ ❑ I
LICENSED ONTR underp DECLARATION L[T-
I hereby
Section7(Ithat1 wisdonsedunderpessalonsof ed onsr9(conunenc-I (APPLIANCES-RESIDENTIAL OU PSCRIT'ION
- Ingwlth Secfon to.of Dlvfect. !the BuelnessandPm(roaloneCode,and my 4 /'
hrense le In full rare and dfect. PANELS ` l ��t�
License Clam It.If
Date Contractor IR'T47.�AhB'S
ARCHITECPS DECLARATION 701-1000 AMM
q�v OXZp I understand my plans shall be used as public records ' OVER 1000 AMPS - SQ.FT.FLOOR AREA p$/SQ.FT. '
I�uE Licensed Profesumill SIGNS ELECTRICAL
6� OWNER-BUILDER DECLARATION ( -(_
7 7,
re
1hebyafum that l am exempt from the Contractors License Law for the# SI'ECIALCIRCUfT/MIST
�Z-9Q following reuon.(Section 7011.5,Business and Professions Code:An d or [
county which rcqulm,a permit tocotatruct,alter,bnprove,dermolbh,orrepair TEMP.METER OR POLE INST. ,
znyanuct ure prbr to its L„uance,also requlrestheappliront forouch permit to (�yypR DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
�O t'In Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- [ I
5 don3 of the Businessand Preealom Cod0crthat he la exempt therefromand SW24MING POOL ELECTRIC I - VALUATION ;
the bash for the alleged exemption. Any violation of Section 7¢11.5 by any I �G/ , 6,V the hcam fora alleged exemption. llcy vioation of vltyof nu more than# DDTLE7S5NOTG1iESFTXTUItES p +I o 6
If I ndred dollars($509).�n I,as owner of the property,or a'7 employees with wages r there cue
NEW RESIDENTIAL ELECTR SQ.IT. STOIiIIS TYPE CONSTRUCTION'
rom(Sac.70K Business and kandthes Code:reh notintended orcenseLmr i
q nile to Business owner Predessions who builds Contractors I hemoelaw
whodeamich roanowner orp rough whonemporlmprov.,thereo Rand OCC.CROUP RES.UNITS
whodocaeuch work hlmseBorthreugh his ownemploy ero,provided tha4.,: - 'p
improvements are not intended Grofferedforsale.If,however,thebulldingor TOTAL:( Q
Improvement laeold within one yearof completion,the owner-buRderwill have
t1�¢nMen o(proving that he did not bind orlmprove for purpose ofealeJ, a, lP',PLUMBINC PERMIT ' '[""FEE � FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed ppRgT ANTE
ronmicto a to coratmct the project(Sec.70N,Busing and Profeselotu Code:
The QOnlmRars Wrense Law does not apply to an owner of property ALTER-D N&VENT-WATER(FA)
Wilds or Improves thereon, and who contracts for such ptopcts with a
cpRlrector(e)Ilren,ed pursuant to the Contraeor'a License Law. BACK FLOW OT T.DEVICE I 1" FEE SUMMARY'
LI I (exempt under Sec. I B&P C,for this mason quTCgp,n:l,v l
Owner (DRAINS FLOOR OOF,AR[?A CONED SANITARY Y N
. Dal• RECEIPT p
WORKMANCOMPENSATIONDECLARATION '
Of hereby affirm that I have a certificate of consent to self-Insure,or a %NRFS ER SCHOOL TAX Y N
mniRcateorWork m'Campematmn Lauranceorarertifkd copythereof(gees RECEIPT#
GAS EA.By TEM-i IN 40 S
3g00,Lab CJ [ (PARK FEE .Y N
Polity Y GAS EA.SYSTEM- RECEIPT If
Cam any OVER4 )
ECertifled copy b hereby furnished. _ I I BUILDING DIVISION FEES
Certified ropy tsfiled with the city inspection division. eREASE/INDUSIRL EP TOR I PLANCHG[�C�K/F1EG N�•-�y••y/�.ya,.,��
CREASETRAP I PAIDZ=7 -L ` `a a 6 a�
CERTIFICATE COMPENSATION NS FROM WORKERS' I`
COMPENSATION INSURANCE
Rhls sMlon need out be completed#(the permit b(or one Fundred dollars SHIVER- Y-STORM P.A. 'L I Date Remipt#
($100)or lea.) WATER( TER W/VENT/Fl.FLTR cNERCY FEE Y N
I certify that In the performance of the work for which this penult is Issued, - I [ —
I shall not employ any Laws In any manner n.,to become wbject ru the WATER SYSTEM/TREATING
Wcrken'Compenadon laws of California.Date [ (PAID
O Z Applicant I]
Z O NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you'( NEW RESIDENTIAL PLMB._SQJ• . [ 11 Date Receipt#
Hshould became subject to the Workers''Compewtlon provblom of the Labor - I TOTAL:
W Code,you must forthwith complywlthsu ch provisions or this parMtshallbe - [ BUILDING FEE �S'3a0o�
CC j deemed invoked.
dC CONSTRUCTION LENDING AGENCY + [SEISMIC FEE . P
Z Ihembyaffirm thatthcrx a commidton lending agency for the perform- TOTAL: '.I ELECTRIC FEE a� /IVY
O ante of the wark!car which thtspermB b Issued(See,3097,GIV.C.) [ L+
V _ Lenders Name 'PLUMBING FEE
1. H Lender'sAddma - (QTY. MECHPNICAL PERMIT' [ . '.FEE.."IMECFIANICAL FEE
OU Icertlfy that l have mad thisappBcatlonand state thattheabove Information
C incorrect.l agree to comply with all city and countyordlnances and state laws PERMTTA I�FEES PAID:
N relating to Wilding construction,and herebyaulhodze rcpresentalivesoftMs
Z city to enter upon the abovcmenrioned property for lrapMlon purposes. ALTER OECH. [ Date ReCelpt#
V - (We)agree to save,Indemnify an d keep hinern.the City of Cu Perrino agar Ntica,)adgnenb,costs and expenses which may In any wayacome (AIR HAG010,000CFM�I I SUBTOTAL:
b In consequence of the grantla ftM+pgmt�ro �7 AIRHAN (OVF�CFM) [ CONSTRUCTION TAX
amm of AppBn //Cooninieur n� — ��' FXHAUS77 I +CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSe Will theapplhant or fumm building occupant store or handle haurdous HEATIN00, BTU) [ I Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9,12,and the
❑ealthand Safely Codr Section 15532(aI? HEATIN1 000 BTU) [ TOTAL:
Yea No ll the applicant or umrebwlding occupant use equipment or deviceq VFN .A1NGL'RESIIJ) I I$$ I�jVCp T1A•FE
which emit harardous air contaminants.,defined by the Bay Area Air - �NAW9RQi/�
Quality Management Dldnet? ER-COMP pIR'pR100,000 BTU)
q Yes No
V have read the hazy us rtatedals requirement under Chapter 6.95 of I BOILER-COMP(OVER 100,0D0 BTU)
the California Health&Safety Code,Sections 25505,M533 and 25534.1 11 P9 a�
understand that if the building does not currently have a tenant,that it ismy NEWRESIDENTIALMECEI. SQ.IT'
r poralbilitymnadytheoccupcent fthe rcquu mentswid,h at barred
pnort anre of aCertificateof Occpan5e._ i [ a
-
r or authorized agent Dj1p.p - -ETNA LZI! .
e 2. •7 - /�I I TOTAL: [ISSUED BY: - iT'4Y.
OFFICE COPY