21780 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add res.:
21 n 1 oO 0
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Photo:
CITY OF CUPERTINO-BUILDING DIVISION
e ra r.N.me; Lie.No: APPLICATION I PERMIT
raSIN BUILDINO-ELECTWCALPLUMBINGMECHANICAL CATEGORY CONTROL#
Arch ted/Engineer. I.ic IJo;
1A7�']�L1'1GI�L) Q,fy .ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address _b"'� - PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby auto that l am licensed under,provisions of Chapter 9(ammrn APPLIANCESRESIDENTIAL
ingwith5ection7000)o(Dlvislon3 oftheflusinessand ProfessionsCode,andre �M, JOB DESCON
B� u
licence ie in full jo d cited. PANELS
Llansq LI
Date_ Contractor UP TO 200ANTS #—
ARCHITECIPSDECLARATION 201'1 WO AMPS
Ore Z I understand my plana shall be used as public reards, OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
res SPCCIAL CIRCUIT/MISC
Z' owing reason.
(hat I alon 7 exempt froBusiness
and
Prefctorb s Code:Law for the
O Z ^ following reason.(Sectors 7 tto Business and Professions Cade:Any dry it TpAgp,METIR
r�„ CYar] countywhkh rcqulresa permlttomwtvcq alter,impvve,demoBah,orrepalr
anystmmmpdortoiteumanc,alis.requlrestheappllantforsuchpermhto POWER DEVs
O 5 file a signed statement that he Is Recessed pursuant to the provisions of the N
Contractors License Lav,(Ch er9(commencin with Section 71100SWIMMING L CR(IC).!Dlvl- 1/
_ I',"M
„SOS don3ofthe Busi msmdProfemloro Code)orthatheisexempttherefmmand J .✓ VALUATION
the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETSSWITCHE^.FIXTURES
DA
five
hundred apermi($500)ctsthe applkanttoa dull perulty of not more than
�c flue 1,as o nerdolof the pr. STT3 ES TYPE CONSTRUCTION
�I,as owner of IM property,or my employees with wages as their sole NEW RGS(Dp-N71A
7a rompen.ation,wllldothework,andthestvctum beet intended or oflemd for
O sa1e15e,7044,Business and Professions Code:The Contractors License Law
5$ does not apply to an ownerof property who builds orimprovesthereoR and .00C.GROUP RES.UNITS
whod.essuch workhimseif orthmugh Msownemployees,provided thalsuch
Improvements arc not intended otoffered for sale.If,however thebulldleg or .TOTAL:
Improvement!..old withinoneyearofcompletloo.theowner-buRderwlll have
the burden of proving that he did net build or Improve for purpose oftole.), QTy: PLUMBING PERMIT FEE FLOODZONE APN
u L as owner of the property,am exclusively contracting with licensed ppRMRLSSUANCE -co
contactors to construct the project(See 7044.Business and Professbw Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN h VENT•WATER MA)
Wilds or Improves thereon, and who contacts for Much p4ojects with a FEE SUMMARY
<gR[pdor(s)licensed pursuant to the Contradole License Law. BACK FIAWPROTECT.DEVICE
Ll l am exempt under Sec. B k P C for this remenOUTSIDE FEES
Owner Date DRAINS FLOOR{ROOF,AREA,COND. SANITARY V_ N_
WORKMAN COMPENSATION DECLARATION RECEfIT p
hereby affirm that I have a artifiate,of consent to self-insure a a FIXTURES.PER TRA? SCHOOL TAX Y_ N
¢nifia ofW.rken'Compensatloninsurana as anlfkd copy rhereo!(Sec. RECEIPT#
3800,Lab C.) GAS RA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
PolicyN �— � RECFRTN
Ce W yo
PA.SYSTEM-OVER 4(FA)
Com any S BUILDING DI VISION Fr.FS
ertified ropy is he d with t e city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
ertl(led ropy b(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTAAV-STORM CA.21)OFT. Date Recei t#
(TMssedion need net W completed If the permit is for one hundred dollars ra
($1W).rless.) WATER HEATER W/VENT/ELECTR e/ �+� ENERGY FEE Y N—
I mnifythat in the performance of thework forwhlch this permit is issued, �L't..J
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATINGWorker?Compensallon Laws of Calltornla.Date PAID
Applicant
Z Z NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
NOAPPLICANT:If,after making this Certiflare of Exemption,you
should besubject to the Workers'Compensation provisions of the Labor TOTAL:
CC rorre(A Code,you most forthwith comply with such provisions orthis permit shall be
> deemed revoked. BUILDING
LU c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform #� ELECTRIC FEE
Z ance.fthe work forwhichthis permit is Issued(5ec.3097,Civ.C.) TOTAL: (k�
U O Lender.Nara PLUMBING FEE
IL F Lcedcr.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO Icertlfy thall have read thisapplicatlonand statethatthe above information
0. brored.l agree to comply withal)dtyand county ordinances and state laws PERMITISSUANCE FEES PAID:
>. N relating rebuilding construction,and hereby authorize representatives of this
(— Z city to enter upon the abovcmenrioned property for inspection purposes. ALTER OR ADD TO MUCH. Date Recel t#
_ (We)agree weave,indemnity an d keep harmless the City of Cupertino P
against halubtles,judgments,caYeand expenses which may in anywayamrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in "ence of the granting of this penNt.
AIR HANDLING UNIT(OVER 10,WCFM) CONSTRUCTION TAX
Signatureof Applicant/Contractor 's �at�"-"— ECHAUST HOOD(W1 DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle huardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health.ed Safety Cad cion 75532(.)? HEATING UNIT(OVER I f,"BTU) TOTAL:
❑Yes No
Willtheapplianto, re building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air ocntandeants as defined by the Bay Area Air PAID
. Quality Management is d7 BOR-ER-COMP OIN OR 100,0(q BTU)
Y. No F
4have real the haz.r ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Ca Lf.mi.HealtLASafMy CW,Se t..25505,25533.nd2MU.I F �
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff.
responsibility to notify the occupant of the requirements which most be met
prior to cauan of a Cert•ifi^cateof Occupancy.Owns raurhodud agentDat¢ ISS4-: 1"
TOTAL:
OFFICE COPY