21943 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'ed Identification - PERMIT NO.
Building Addess e
21943
1 hone: A
'—� b'�.rlriw��✓ CITY OF CUPERTINO-BUILDING DIVISION ��-j
co .due.Name: Lie N.: APPLICATION / PERMIT
DAN I , LV BUILDINGELECTRICALPLUMBING-MFLHAMCAL CATEGORY CONTROL
911(GGct/te�n neer. Lie.No:
--cu W Lb#n[LvIJQ s� - t BUILDING?E_RM1T4NFO'
I�,� •QiY '�ELEC'`i'RIC PERMIT� FEE,
Add�PH y/ w `K 4 PERMITISSUANCE - '],g (� ❑ 1:1LICENSEDCONTRAcT R'S DECLARATION f�
I hereby affirm that l am licensed under provisions Of Chapter9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION .
Ingwith5 dion7000)ofDlvielon3oftheBusimssandProfesslonsCede,and my S�I s n'I e
license is in full form and effect. PANELS
LicenseClass Lie.#
Date IM7,Q200ANU
ARCHITECPS DECLARATION 201-1"AMS - x+ I I✓•'—
{Qq re0 7p .. I(ends t�' a d my� shoo be4�Qpu�`cords. OVER 1pq AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E b. Lim(sed essim51 • SIGNSELEC'FRICAL t .-
< OWNER-BUILDER DECLARATION
!`n] SPECIAL CIRCUIT/MISC
7 I hereby affirm that 7 am exempt/mm the Contractor's License w for the '
(O� following reason.l5ectlon 7QdlS,Buelnese and Profeulone Code:Any city or
Fe'ly cvuntywhlchmqul aper tmmr tmMalter,4npmvgdemolbh,orrepalr TEMP.METER OR POLE INST. ,
E X77ny structure prior to its Issuance,also requires the applicant for such permit to
a ]A7WFR DEVICES
U file a elgnetl statement that he is licensed pursuant to the provisions of the -
O Contractor's License Law(Chapter 9(commenciegwith Section 7000)ofDivi-�0 the laofehe Ile alleged Pemption,Code)irlation f exempt 7MI.5 by
SWIMMING POOL ELECTRIC VALUATION
�.' the bas's for the alleged exemption. Any violation of Section 70)1.5 by eny.
applicant fora permit subjedsthe applicant tai civil pewlty, exam are than OUTLETSSWITCI{ESEXTUIRFS
five hundred dollars(SM. NEWRESIDENIIALELECTR
❑I,as owner of the property,or my employees with wages as their sole SQ.FT. STORIES TYPE CONSTRUCTION
cmpensation,will dothe work andthe structum is not intended or offered for r9 ��
O sale(Sec.7014,Business and Profession,Code:The Contractor's Lt..Law a `•a
�$ does not apply to an owner of property who builds or Improves t hereon,and - OCC.CROUP RFS.UNITS
who domsuch work himself or through his own employees,provided that such
I Improvements are not Intended or offered for sale.If,howeveq the building or TOTAL: aCV
improvement Lisold within one yearofcompletion,the owner-but llderwill have
tl�yLden of proving that he did not build or Improve for purpose of sale.). QTy,' �''PLUMBING PERMIT ,.F$$• FLOOD ZONE ApN
LJ 1,as her o!the property,am exclusively contracting with Ilrensed PERMIT ISSUANCE
contractors to construct the pmja[(Sec:7014,Business and Profeadom Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN AVENT-WATER(EA) r
builds or improves thereon, and who contracts for such pkojects with a
ador(e)1lrensed pursuant to the Contnctor'a Llrense Law. FEE SUMMARY
I am exempt under Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE
OUTSIDE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY YN
Date RECEI'Ta
WORKMAN I have a COMPENSATION DECLARATION FIXTURES PER TRAP -SCHOOL TAX Y_ N
❑I hereby affirm that I have.a Insurance
a c of consent to copy
thereof ora RECEIPT#
3800,conifiLab
orarertl(Ied copythereoft5ec. GAS EA.SYSTEM.1 INC.4 OUTLETS PARKIN Y N
Polis lab CJ
Polity It - — RFGFIM X
Cam GAS EA.SYSTCM-OVER4(EA) BUILOINC DIVISION FEES
CertNed copy It hereby dwith the
GRP.ASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified ropy I.filed with the city inspection division.. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
net becmplewd
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.200FT. Date RCCCI
- (T-Hre len need not be completed if the permit bfor o'ne hundred dollars _ PI
($100)orlyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cartilll net that o any personhe Ian the nwork
er so as;to b co perm) ct to he —
I shall not employ any person In any manner ro n,to become subject to the WA TER SYSTEM/TREATING
Workers'Compensetlon Iowa o(Gllfomla.Date PAID
O Z Applicant
ZQ - NOTICE TO APPLICANT:If,after making this Corti(lateo(Exem)ation,you NEWRESIDENT(AL[PLMB, SQ.FF. ' .DatC Rewi t#
L0shouldbecom inibjm to the Workers'Compensation provision,ofthe Labor TOTAL:
Cade,you must forthwith comply with such provisions orthla permit shall be
U > deemed revoked. _BUILDING FEE 3 a
W
a — CONSTRUCTION LENDING AGENCY SEISMIC FEE N—
Ihereby affirm that there Is a mmtruction lending agency for the perform( ELECTRIC FEE "71L 1T)
O ante of the work for which this permit is heated(See.3097,Civ.C.) TOTAL:
O Lender'sName - PLUMBING FEE..
Iy F- L.eedW.Addreu QTY. MECHANICAL•PERMIT', FEE': MECHANICAL FEE
O,W Imallythat l have reacithbeppliatlonand statethat the above information
IL is corms.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorize representatives ofthb -
♦••• Z sty to enter upon the aleve-mentioned property for inspection purposes.- ALTER OR ADD TO MECH. Date RCCet t#
(We)agree to save,Indemnify an d keep harmiess the City of Cupertino P
against liabilities,judgments, s and expense whlchmayinanywayaceme AIR HANDLING UNIT(T010,000crm) SUBTOTAL: '
agar' told Clty In consequen o egrantl go"aa permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER IO,000CF-t)
f CONSTRUCTION TAX PAID:
'Ign, of A4 a t/Contractor ate IX}IA(IST HOOD(W/DI1C'D '.
MATERIALS DISCLOSURE
e a pPllcant or future bu Ing occupant store or Fondle hazardous BEATING UMT(TO 100,000 BTU) Date ReCCi t#
ectal as dullard by the Cupertino Municipal Code,Chapter 93Z and the
Health and Safety Code Sedlon25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:❑ Yes , t]No
- Will the applicant or future building occupant use equipment or devices VEN"DLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? - BOILER-COMP OHP OR 100,0(0 BTU)
4 Ye No
I havemad the haze lett'Code,Sections255unlsunder Chapter.1 of BOILER-COMP(OVQt 100,000 BTU)
the• J undcaltforate}Iralthk Skiing Code, currently
have.3 andmean 2553t.1 /��Y (IQ p
understand that It of the
of
the
requirements
which
that itis my NEW RESIDENTIAL MECFi. SQ.Ff / N
responsibility re of notify tris occupant of the requlmmenb which mus(be rrct 21�7`�1
prior to bsmnce o(a CrrtiOcate of Occupancy.
Owner or authorvcd agent - Date ISSUED BY
s 0•.
TOTAL.:
OFFICE COPY