21861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER ITNO.
Building Address: 2 1 8 6 1
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A A
CITY OF CUPERTINOLBU1LDING DIVISION
tractor's Name: Lie.Na: APPLICATION / PERMIT
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3 22BU LDING-EIEC R CA4PLUMWNG-M L1 AMCAL CATEGORY CONTROL x
A¢hitut/Engine r. Lk.No:
C_ F'' QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: AA 52Nt)0RC PERMITISSUANCE ❑ ❑ r;71 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commune APPLIANCESRESIDE.NTIAL JOB DESCRI'TfON
ingwith Section 7000)of Division 3 oflhe Business and ProfessionsCode,and my
Licurs Is in s farce and effect PANELS ["q� .S . r(7
License Cls® Lffec I`/ v "M\'9`'"61 `
Date Contractor
ARCHITECTS DECLARATION 211-IOW AMPS
NO Zp20 I understand my plans shag be used as public records. AA
0 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
ZU Licensd Prdesalovl SIGNSCTRICAL
�i6k6S OWNER-BNLDER DECLARATION IRCUIT/MISCIherebyafOrn thatI am exempt fromthe Contractor's License law for thefollowing reason.(Sectim 7IDL5,Business and Profe s ions Code:An ciorcounty which requires a permit to construct,alter,improve,denolbh,ortepair TEROR POLE INST.qanystmu mpriortoib Issuance,al mquirestheappUantforsuchper ttoE�v.� aIle a signed aGtement that h<V Ilcensd pursuant m the proNolons of the EVICES3 OContractor§License Law(Chapter 9(commencingwith Section7000)ofDivi- G POOL ELECTRICsion3oftheBus nandProfe Wb Code)arthehebexemptthercfromand - VALUATION
the basis for the alleged exemption. Any violation of Se tion 7031.5 by anypplicant fora perMtsubjets the applicant to a civil penalty of not morethan SMTCHFSR)MTRESfive hund11,as o nerdolof the W). DENTIAL ELECTR❑7,as owner of the property,or my employees with wage a theb sokSQ'r' STOW ES TYPE CONSTRUCTION
compensation,will Bothe work and thestruture la not intended or offered for
O sale(Sec.7044,Business and Protrusions Cade:The Contredots License law
S$ does not apply to an owner of property who Wilda or improves thereon,andc.
who doeasuch work himself orthrough his own employees,provided that such OCC.GROUP RIS UNITS
improvements are not Intended oroffered for sale.R howevep thebullding or TOTAL:
Improvement issoldwithin m eyearof.ropltion,theowner-builderwill have
th6I,rden of proving that he did not build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE p( ,zoNNE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contraction,to construct the project(Sec.7044,Business and Professions Code:
The Contmtore License Law does not apply to an owner&property who ALTERARAIN&VENl'-WATER(EA)
Wild.or improve themmn,and who contracts or such ptujecb with a
cga1Jator(s)licensed pursuant the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION - RECENTN
L,pr hereby affirm that I have a cer iRvte of consent to aeB-Insure,or a FIXTURES PER TRAPSCIiOOL TAX Y N
certificate of Workers'Compevationlesurance ma certified capythereof(Sec. RECEIPT N
MW,Lab C.) GAS EA.SYSfEM-1 INC.40UILETS PARK FEE Y N
PaBryN_ /.-NTM--(ryLA Z�9.Y04J9 RECEIPT-
—ga^y a70 morbL�a $ GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
LCenifkdcopyL rcbytuMshe6!i
OCertlBd mpyb(iled with the tty inspection divlslon. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(rhissectionneed not becompltd ifthe permit isforovhundred dollars SEWER-SANITARY-STORM EA.XIOFT. Date Rewi til
($1I dfyth) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ceout that in the performance any
work(ors to b this permit d to the
1 shall not employ any person I.any manner so ns to become subject to the '
WoCompensation laws of California. ERla.Date WATSYSTEM/TREATING PAID
O Z Appllunpgcant
Z O NOTICETO esob)e ante, after rs'Co po cation,pro is Exemption,you NEW RESIDENTIAL PLMB.—SQF T. Date Reeei t#
F Code,shoulyou
most
forth itis co Workers'Com provot n provuionsrmit of s Labor TOTAL:
� N Code,you must forthwith comply with such provisions or this permit shall W
W > denmd revoked. BUILDING FEE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them i a romit is E un lending agency for the perform
7 Z ance Lcoderthe work for whkhthb penNtbtuvd(Sec,30Y7,CIv.C.) TO L: VC ELECTRIC FEE
U O is^ser'sName PLUMBING FEE
IL t.e^deraadd. QTy. MECHANICAL PERMIT FEE `
O W Icertifythat l havereadthis appBmtiona^d etatethataheaboveinformaeun MECHANICAL FEE
G emevc.lagreetocomplywithalldtyandcountyotdinancesa^drtatelawa PERMIT ISSUANCE FEES PAID:
>. relating to building castmdlon,and hereby authorize representatives of this
(— Z city to enter upon the above-mentiond property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,indemnify an d krep harMess the City of Cu pentino Date R2Ceiptll
aga out liabilities,judgmems,"..nd expenses which may in any way accrue AIR HANDLING UNIT(To I e"CFM) SUBTOTAL:
against said City in consequence of the granting of this perm
q r AIR HANDLING UMT(OVER 10,0911 CONSTRUCTION TAX
IS. ef Applin`-/ ono-�dor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAIHA 0 SMATE IALSDISCLOSUREhe appllcantorfuture building occupant store or handle hvardous1=__R__ MTAL
UNIT 100,000 BTU)
material as defi red by the Cuperd on Mu nicipaf Code,Chapter 9.17,and the _ Date Recel tit
Ilea lthand Safety Cde,Sectloon 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL- l
Will the applicant or❑future building rampant use equipment or devicesN PAN(SINGLE RESID) J$$[J CE rsa.I.E
which emit hazardous air contaminants ao defined by the Bay Area Air Gi'►�i1`E�ffi•
•
Quality Management District? BOILER-COMP OR 100,0(q BTU)
4yea
havercadthe hazaQousmxtim.lsrcqulrcmentsu^der Cha poor 6.95 of BOILER-COMP BN) �� q 1�9�
the Califemla Health&Sa fety Code,Set loss 25505,25533 and 75534. 1 F 4a l
underoa ad that if the building does not m reently have a tenant,that It k myNTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be mot
prior to Issuance of a Certificate of Occu pa ncy. CU . •I
Owner or authorized agent Data j ,�.(g�N'w�P_J_��®
TOTAL: ISSUEDBY:'-\�\' ' `—
OFFICE COPY