21859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
/?Go0 HrJrX44014
nems amc: one:
A A
CITY OF CUPERTINO-BUILDING DIVISION �r ^ r• �/
c°ntia °raNa"e: plo '?z Lie.No: APPLICATION /PERMIT L i�
/O so / BUILDING-ELWTMCAL-PLUMBING- CATEGORY CONTROLN
Architect/Engineer. Lk.N. MFLFIANICAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ap ❑ r'� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of ChON
I her Sectioby 7000).00 that lamsionsed 3.ftheerp ass and so(Cssions9(commme MPLIANCESRESIDENTIAL JOB DESCRIPTION
IngwithIn full force
fd efeon3o(the Business and Professions Code,and my
Lt. is In full force and e. '3� W PANELS
License Cla G Lie. SW QO V
Date ContndorM11-7'44
ARCHITECIpS DECLARATION 201-10DO AMPS
ce0 7 I understand my plans shall he used as public records. OVER 1000 AMPS SQ.FT.FLODR AREA S/SQ.FT.
O
mdo Licensed Prefesstroul SIGNS ELECTRICAL
G
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Ihereby affirmthat lam exemptfromthe Contractor's License Law for the
7 O.. following....(Section7(01.5,Businessand Profession.Code:Anydtyor
TEMP MEM OR POLE INST.
c°untywhirh rrquireaa issuantocongmuirestheaprovst forsuch,ormatto
m a any stmtturetatemeltahat he
licensed rersuant to the rovislhpeof to POWER DEVICES
CO V Ole a signed statement that he b r 9(cam pursuant it the provisions of the
Contractors License Lw(Chapi.� Cmmenthath Sention Divi-
It SWIMANG POOL ELECTRIC
O� e1on3o(the Budnessand Professions Code)orthat hes emmpt therefromand VALUATION
S yd•.t the basis for the alleged exemption. Any violation of Section 7031.5 by any
��165 OUTLETS S
apPBam
nt for a permit subjects the applicant to a civil penalty of not ore than WITCktESFIXRAtES
r. R five hundred dollen($500). NEW RESIDENTIAL ELECTR
I,as owner of the roe SQfT STORIES TYPECONSTRUCUON
7 ❑ property,ky,or my employees with wages r thele door
C < compensation,B.iaosthe work rand the structure ode:Thn ontrandedo License
ed for
Law
D sale(Sec.apply
to an ow and Professions Code:The Contractors License law
SQ does etaapply torn owner ofpropertywhoa ilds emoyees,pvnted that such
OC RES.UNITS
-
Improvements
ho eatsuch am nothimself dedoroughhbownemploynseverthdedildingch C
improvementsarenotintended earofto for sale.ILhaweveptheerildingve TOTAL: .V•
Improvementbsoldwithin oneycarofcompieliontheowner-bu0derw111have
t"Men of proving that he did not build or Improve for purpose of saln.). QTY, PLUMBING PERMIT FEE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /
contactors to construct the project(Sec 7044,Business and Professions Code:
The Contractors License taw don not apply to an owner of property who ALTER-DRAIN k VFM-WATER(FA)
Wilda or Improves thereon, and who contract for such ptojerts with a
,,ne{arterial homaed pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Sec B Na P C for this reason BACK FLOW PROTECT.DEVICE OUTS I DE FEES
Owner Date DRAINS FLOOR RODE AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION FRECEIPTN
❑I affirm that I have a certificate of consent to sure,ora FIXIVRES PER TRV' SCHOOLTAX Y N
rekiflatete of of Workers'Compensatlon Wuranre ora rertifled copythpythenrof(Sec. RECEIPT N
3B00,lab C.) CAS FA.SYSTEM-t INCA 0UTLETS PARK FEE Y N
Policy N RECEIPT N
C[3' GAS EA.SYSTEM-OVER 4(EA)
Certified copy Is hereby fuMshed. BUILDING DI V iSION FEES
❑Certified copy Is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF IXEMPTION FROM WORKERS' GRFA-SETRAP PAID
COMPENSATION INSURANCE
(Thlssection need not be completed if the permit is forone hundred dollars SEWER-SANITARY-STORM M.200FT. Date RL'Cel t#
(810(fiorlrss.) WATER HEATER W/VENT/m rrM ENERGY FEE Y N_
I certifythat in the performance of the work for which this permit Is blued, —
1 shag not employ any person In any manner ro ajo b¢rpgie su to the WATER SYSTEM/TRFAUNG
Workers C. rasa w 1vrnNa.Date �.L_i( 7 PAID
Q Z APplkant
Z O NOTICE TO PLICANTa,aNer making thio Certiflate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei f#
should sem subFct tothe Workers'Compensation probiiens of the Labor TOTAL:
N Code,yeu ust forthwith comply with such provisions orthb permit shall he
W > dermed revoked. BUILDING FEE
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirthat there b a construction lending agency for the perform.
ZO ance affirm that
the work for which this perout is boned(Sec.3097,C1v.C.) TOTALELECTRIC FEE
:
V Lenders Name PLUMBING FEE
LL ~ Lender's Addmss QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I cert Bythat l have read this appliation and statethattheabove Information
6, iscorrect.l agree to complywlth all city and county ordinances and gate laws PERMD'ISSUANCE FEES FA-
ID-U) relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for inspection pu rpows. ALTER OR ADD TO MECH.
V — (We)agree to save,IndemNfy an d keep harmless the City of Cu Fenton Date Receipt#
against Babilitles,JJdgments,matsand expenses which may In anywayacaoe AIR HANDLING UNIT(TO 10,0DO CFM) $U$TOTAL-
agal dC7r Jea�
niy mm�aryuenre of the granting Mthle permit.
AIA FIANDLING UNIT(O VER I0,000CFM) CONSTRUCTION TAX
Si tore of ApplIant/Contractor Date IXFIAUST HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
ill
the applicant or future building occupant store or handle hazardous HEITINC UMT(70IfD,030 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reuel t#
Ifilthand Safety Code Section 25532(.)7 HEATING UNIT(OVER I f1,000 BTU)
71Yes r]No TOTAL:
Will the applicant or future building nompant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousm
air coma inhoods m defined by the Bay Area Air
Quality Management F1 No BOILER-COMP MIT OR 100,000 BTU)
4Yea ❑No `PJsF r9'R!
havc California
the Health
Safety Code,
requirements and25534.1r Chapter of BO LER-COMP(OVER 1 q,000B U) i��� iQ
the
erstandthat if the building
Safety Cods otcons mently have a 3and2rihatit FErs m
understandthat if Wild ingdoed of t e rrentiyhsontsw which
that it busy NEW RESIDFNIIAL MECH. SQ.FT R
morto iissato notifythe onte of oftherequirementswhich must be met
prior to Issuance of a Ceriltkate of Occopancy. •Ino
at
Owner or aulhorieed agent Date ISSUED Co N
TOTAL:
OFFICE COPY