21549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PELMITNO.
Building Address: , t I 21549
l qq,9 d �
sonar.Name: one APPLICAT
, A ATr
VLnW CITY OF CUPERTINO-BUILDING DIVISION
° tractors Name: � a��5-Q� Lic.lyo: APPLICATION I PERMIT I 1
pa-2 Ia'Vu"�'�T C BUILDINGELECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL p
rcrusct/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERNBTISSUANCE 2x Qj ❑ .�/I ❑ ❑
LICENSEOCOensed under
der pr DECLARATION L�'�
Ihereby Sectin700(fatl amBon3ofthderprovtslonsof Cha)rter9(m and
APPLIANCFSRESIDENCIAL JOB DGSCRD'RON
Ingwlth Sen fon7000)0(DiWslon3ofthe Bualnessand ProlesslomCode,and my
license Is In full(o and died. PANEIS
License Cis C_r�Llep
Date=2. �Contrador �(r��- UP TO200AMPS
ARCHITECT ECLARGa" TIOA N 701-1000 AMPS
7 I understand my pore shall be used as public remNs. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
OC
QC
U - Licensed Profeaslowl SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIAL CR2CUIT/MLSC
7f' � Ihereby affirm that am exempt from the Contractor's License Law forthe
following reason.(Seaton 70715,Business and Professions Code:Any dty or
K fp'� county which requlreaa permit tommtmct,alter,improve,demolish,orespalr TEMP.METER OR POLE INST.
�� anyatructure priorto Its Issuance,also requireathe applicant forsuch permit to POWER DEVICES
C file a signed statement the he Is licensed pursuant to the pre,himu of the
3aG Contractor's License Law(Chapter 9(commenting with Section 7000)of Divi- SWC.SMING POOL ELECTRIC
PHOS sbn3hfthe Busis.and Prefemlore Code)orthat heV exempt therefromand VALUATION
�°•.1 the basis for the alleged exemption. Any violation of Section 7031.5 by any7-1
<�
applicant for emut sub' ,theapplicant to a civil 1 of nee more than UTLETSSWITCHFSFIXTURES �Os�
155 po five
P 1� penalty
c, u. Ove hundred dollars(5500).
41MW RESIDENTIAL ELECTR __TT RIES�n ❑I,as owner ll the property,or my employees with wages r thele sole �'FT TYPE CONSBUCTION
m(Sec.70K Business and
Professions
Cde:Them Contrandedorcensed for
Law
sale(Sec.apply
to alnowner f peapeore Cod e:The orimp rnes License Law
S$ whoa not apply to work
owner of property who builds or improve thereon,and OCC.GROUP KISS UNITS
who does
mnu a nrk to do oroffe his own le.Iflyees,providedthatsuch
Improvement beald tininone arofc plem .lf,howevep Elder ilI havedingor TOTAL: S lQ
Improvement 6sold withinoneyuarofcomplelbn,theowner-bu0derwfll have
th,q*Hen of proving that he did not build or improve for purpose ofsals.). QTy, P UMBIN ERMIT FEEFLOODZONE APN
L j L as owner of the pmpedy,am exclusively contracting with licensed PERMIT] NCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractor's Llceree Law does out apply to sn owner M property who
builds or Improves thereon, and who contracts for such p(ojects with a ALTER-DRA V -WATER(EA)
c°,,WWfIactor(s)licensed pursuant to the Commeterb License Law. BACK W T.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this mason
OUTSIDE HTS
Owner Date DRAINS I,AREA,GOND. SANITARY Y_ N_
WOR XMAN COMPENSATION DECLARATION RECERT0
01 hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES SC TOOL TAX Y_ N_
1 cenl(Iczte ofWorken ComperuationlruunnttoraartBied mpythereo((Sec. RECQPfN
(� C 3800,Lab C.) EA. -1 .4 OUTLETS PARK FEE Y_ N_
✓ Policy RECER'rN
Com any A& R (EA) BUILDING DIVISION FEES
Red ropy is he iehed.
CcrtBied ropy Is(sledd with
ith t the city Inspection division. GR DU L W I R PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GR PAID
COMPENSATION INSURANCE
(hlasectfon need nor becompleted ifthepsrmft Lsforone hundred dollars -mss Y-STORMFr. Date RCCCI f#
($100)oI ICS9.)
Icertifythat lnthe performanceofthe work forwhichthispeamtt isissued, WATER HEATER W/VENT/E, ENERGY FEE Y_ N_
I shall not employ any person in any manner w as to become subject to the
Workers'Compensation Laws of California. Date WATER SYSTEM/TREATING
O PAID
Z Applicant
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,FT. Date Revel t#
should become subject to the Workers'Compensation previsions of the Labor TOTAL:
W~ (A Code,you most forthwith ply withsuchpmvbloreorthbperntshalthe
j deemed revoked. UIL NG 'E
CL O CONSTRUCTION LENDING AGENCY SEISMIC PEE
= Z I hereby affirm that there u a construction lending agency for the perform- TOTAL: SEISMI FEFEE
ance of the work for which this permit b based(Sec.3097,Civ.C)
V O Lenders Name PLUMBING FEB
1L F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify thatl have read thwapplication and ntatethatthe above Nformatlon
1 bcormd.I agree to complywith all city and county oremances and state laws PERMITISSUANCE FEES PAID:
} W relating to building construction,and herebyauthortmerpmeentativesofthis
1— Z city to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless;the City of Cu Ferris° Date Receipt#
against lialylliln,judgmenb,cmt8 nd expenses which may In any way areem AIR HANDLING UNIT(TO 10000 CFM) SUBTOTAL:
agal (I Clty m)1; ens of the gr Ing ef this permit.—
AIR HANDLING UNIT(OVER 10,WDCFM) CONSTRUCTIONTAX
Sign umo( ph ontranor Date ID(RAUSTHOOD(W/DL :T) - CONSTRUCTION TAX—PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfmam building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTII)
materials,defined by the Cupertino Municipal Code,Chapter 937,and the Date Reeei t#
I lealth and Safety Code Section 25537(2)1 HEATING UNIT(OVER 100,000 BTU)
F1 Yen r]No TOTAL: (�
Will the applicant or furore building occupant use equipment or devicesRRESIDEN-nAL
FAN(SINGLE BE ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qu'lity Management Ostrid7 OR10B
Y. F�No
END
4havcreadthehazar�i'ousmateriabrtquime nbunderChapler6.95ofIW,IX
the Gliferoia Ileeth&Safety Code,Sections 25505,25533 and 75534.I
understand that if the building docs not currently have a tenant,that it Is myMECH.responsibility to notify the occupant ofthe requirements which must be Tref Prior to Issuance ofa Certificate ofOccepaney.
Owner or authonzed agentDate ISSUED"'
OFFICE COPY