21762 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address: 21762�q o0p N-�b'(,�S EZPr
x Name: III,ane. APPLICATION TE
CITY OF CUPERTINO-BUILDING DIVISION SUBMITTALA
mtractor's Name: Lie No::: App LIGATION /PERMIT
BUILDING-ELFCTMCALPLUMMECFIAMCAL
tt99 JBING- CATEGORY CON-;SS2
Architect/Engineer. He.No:
QTY ELECTRIC PERMIT 1^FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE YC.b ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
thb ion7OODatlam Vcm3.fthunder ugneprovisions ol Chapter9(wronscrec.
my MPLIANCESREADENTfAL JOB DESCKB'1ION
incense 1.I tion force anDiWfect. (<he Buslnessandl'rofnvonaCode,and my �+ n��WD 6j
licence la In full force and affect.a PANELS V•��U� 4j
LIcenLic.p
Date� Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION X11-1000 AMPS
I understand my plans shall W used as public moulds. OVER 1 ODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIItCU1T/MLSC
O Z Iherebyaffirmthm l amexempt from the Contractors License Law for the
Z O -' following reason.(Section 70115,Business and Professions Code:An d
OZF. cozen which Imo r ttommtmd,alter,im Por
TFMP.MEIT]20RI'OLE INST.
F'aQu� ty reqs pe prove,demolisho,erre 'tr
v anystmt mpriortoitausuance,aL requlmtheappllcantforsurhper it. TOWER DEVICES
Ble a shed statement that he V licensed pursuant to the provbioru of the
g3u,y Contradoes License Law(Chapter 9(commencing with Section 70(10)of Divi- SWIMMING POOL ELECTRIC
O sion3 ofthe Business and Professlons Code)orthat hels exempt therefromand VALUATION
FS g the basis for the alleged exemption. Any violation of Section 7031.5 by any
<�
applicant fora mit sub' thea applicant to a civil 1 of more than OUTLETSSWITCHESFIXTURES
PP Per KEts PP penalty ZOO, O C>O s OQ
o. five hundred dollars($500). NEW RESIDENTIAL ELECTR
[_] SQ,FT. STORIES TYPE CONSTRUCTION 1,as owner of the property,or my employees with wages as their sole -
compensation,will do the work and the structure is not intended or offered for T' 1 I"�
5 O ask(Sec.7094,Business and Professions Code:The Contractors License law 1 s^/ tl'�'
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UNTIS
Ca• who doessuch work himselforthrough his own employees,provided that such �
impowemb
enare net Intended orofferedformle.ILhowever,thebuildingor TOTAL: ^q(w
Improvement issoldwithin omyearofcompletb theowner-buMerwill have
t"oden of proving that he did not build or improve for purpose or sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U I,as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Business and Prefeaeloru Code:
The Contractors License law does na apply to an owner of property who ALM-DRAIN&VFM-WATER(EA)
Wilds or Improves thereon,and who contracts, su
for ch p,"with a
cQ➢_tfador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
DRAINS FLOOR,ROOF,AREA GOND. SANITARY Y_ N_
OUTS I nE FE ES
Owner Date�- WORKMAN COMPENSATION DECLARATION RECEIPT If❑ SadOOL TAX i hereby affirm that I have a certificate ceFIXTURES-PER TRAP Y_ N
rtificate o!consent to seB-Insure,or RECEPT p
38W,Ub GAS EA.SYSTEM-1 INCA OUTLETS
C.)e C.Worken Comperxsationlmurance ora certi(led copy themof(Sec.
380,laPARK FEE Y N
Policy N RECFR'r p
Com any CAS EA.SYSTFAf-0VERd(FA) BUILDING DIVISION FEES
[PCemfted copy 6 herebydwith Ne cityrd. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertVled copy Vfiled with the sty lropectlon division. p �j
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID S /(x•70
COMPENSATION INSURANCE '�ss,a,���rr
(Thisacaionneed not becomplted lithe permit isforone hundred dollars SEWER-SANTTARY-STORM EA.20OF1', Date Remi t#'GY7a
(41 W)otifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill out that In any person i any
lcomner so as to b co permitxobvc issued, —
I shay not employ any person In any manner ou as to become subject to the
Workan'Compematlon laws of California. ATER SYSTEM/TREATING.Date PAID
O Z Applicant
Z O NOTICETO APPLICANT.If,after making this CertBlrale o(Fxemptlon,you NEW'RESIDENHALPIMB. SQ.FI'. Date Remi t#
should becorre sub)ect to the Workers'Compensation provblons of the Labor
y
Code,you=at forthwith comply with such provisions or this permit shall be
W > deemad revoked. WILDING FEE"
Q. G CONSTRUCTION LENDING AGENCY
= Z I hereby affirm that there la a corutrodion lending agency for the perform- TorpL:
ante of the work for which this permit is Iswed(Sec,3097,Civ.C.)
(,) O Lcodera Nam, -
LL0 Iemlerti Addm. QTY. MECHANICAL PERMIT FEE
O W Icenitythatl have read thisappVatbnand atatethatthc above Information
a i+corres.l agreeto comply with all city and county ordinances and state laws PERMITISSUANCE
} N relating to building construction,and hereby authorize representatives,of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to}ave,Indemnify an d keep harmless the City of Cupertino p
ago Inst liabilltie�s,/jju dgnrenm,cod ed expenses which may In any way accrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
���aga Isai ly in quenc h�.egrran/tin$ofthlapemdt. p
,wL: a Ll:��—!/ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigmturc of Appbmnt/C'dnta or I Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
I I,alth and Safety Code Section 25532(a)7
❑Yea HEATING UNIT(OVER 100,003 BTU)M No TOTAL-.74 s
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) F1�ICE DATE
which tout hazardous air contaMwnts as dented by t W Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) ��C7ll
4h ave es read the haz[ materials requirements underChapter6.95o( BOILER-COMP(OVER 100,000 BN) f'lI\ � pa,
the California Health k Safety Code,Sections 25505,25573 and 2M39.I Jai
understand that if the bo fitting does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT. pja. �
rrsponsibility to notify the occupant of the requirements which must be met aft O /1
prior to Issuance of a Certificate or Om pa ncy. (�kf� r�.'p�,���
Owner or authorized agent
Data ISSUED BY:
TOTAL:
OFFICE COPY