21067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuildingAddress:
21067
ner9 dow04KPhone OP
A A
1LC.IAn& P �S CITY OF CUPERTINO-B LPI (VISION q
Contractor's Nam: Lm.No: APPLI
O
C TIN M
CXIOL�RTi/VQ �N\� 7.4F'O'a. BUfLDINGF],EC AL BINGM pl AY CONTROLa
Architect Engineer. Lk.No:
QTY ELEC ERM FE BUILDING PERMIT INFO
l�aa `{5AM-roC,A-San/A!y Up LS 2D.
PERtATI55UhN ❑
LICENSED CONTRACTOR'S DE RATION ❑ N� ❑
I hereby affirm that l an,licensed under provisions of Chapter 9(controme. APPLIANCE&RESIDENTIAL ��DESCRIPION
ingwlth Sooton7000)of Divlslon3 ofthe Businessand PrefesslonsCods,and my ,1�� is�A
license is In full force and effect. PANELS V
Limn CW63-A Ltc.a tfo —'Zg
Date Contractor Kc.P/ 's—
ARCHITECPSDECLARATION ?01-1000 AMPS r
�Op I understand my plans shall be used as public records. OVER1000AMPS SQ.FT,FLOOR AREA
ZLicensed Prof atonal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCDXCUIT/MISC
ph' � IherebyafOrm that lam exempt from the Contractor's Lirense Law for the
following reason.(Section 7MLS,Business and Professions Code:Any city or
F muntywhich requbesa permit tomesnn
truel,alter,Improve,delbh,orrepair ER TEMP.METORPOLE INS('.
anystructure prlorto itsissuance,slso requiresthe applicantfor such permit to
K c. file a signed statement that he V licensed pursuant to the provisions of the POWER DEVICES
3 q Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOLFT,ECTRIC
COs slon3oftheBusinessand Pmfesslmu Code)orthatheboxe pttherolmmand VALUATION
,-, the basis for the alleged exemption. Any ,violation of Section 70315 by any
applicant fora permit subjects theapplicant too civil penalty of not more than OUR.EISSWITCHESFIXTURF5
five hundred dollar(SM.
1,as owner of the NEW RESIDENTIAL ELECTR SQ}7,
�7a com� tlon,wWdo the work,
employees Is net
as offered
dfo SI'OWES TYPE CONSTRUCTION
pSec. k+ndthestrods:The
Contraintenctors
Law
$�(] sale(Sec.7044,easiness and I'rofnslov Code:TM Contranore License law
does not apply to an owner of property who builds or improves thereon,and CGROUPRFS.UNTTS
CC..Y whodoes+uch workhinselforthrough hisownemployres,provided that such
improvements are not Intended oroffered forsale.IL however thebuilding or TOTAL:
improvement issofd withinoneyearofcompldiomtheowner-builderwillhaw
Lhi,burden of proving that he aid not band or Improve for purpose ofsale.). QTY. PLUMBING PERMIT ----
plppp yDNE --TP—licensed
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor,to mratmd the project(Sec.7014,Business and Professions Code: V
The Contractor's License Law does not apply to an owner of property who
wilds or improves thereon,and who rontracts s ALTER-DRAIN&VENT-WATER(FA)for such p5ujedwith a
c LJI
q0[fFEE SUMMARY
�does)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE
am exempt under Sec B&P C for this reason
Owner pwe DRAINS-FLOOR ROOF,AREA COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT p
Iy 'hereby affirm that I have a certificate of consent to self-Inwre,ora F�IVRE,`')'FR TRAP (} Y N
cEnlflcateofWorken'Compersationlr mnmorarenifl mpythemof(Sec. RECEIPT
380,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Paltry a GAS EA.SYSTEN.OVER 4(EA) RECEIPT N
y tlUILDINC DI V ISION FEES
Cen[Red copy b hereby the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cenlfled copy V Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE
(Thissection need not W durpleted ifthspermit Lsforons hundred dollars SEWER-SANITARY-STORM EA.MFT, Date Re i t#
(8100)orfyth) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify employ
the person
theworkso a tobehlsperrnitis Issuedcttoth,
I shall not employ any person f any manner at u to berorts subject to the
Workcrs'Compensatlon Laws o(Calitomla.Date WATER SYSTEM/'IRFATING PAID
O Z Applicant
Z O NOITCETOAPPLICANT:1LaRerrtuking thisCertBicateof Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date R*cei tH
FN come foro
should besubject to the Workers'C. reunion provisofthe Labor TOTAL:
cc Code,you at fon hwlth comply with such provisions or this permitshallbe
W > deemed revokes. BUILDING FEE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
us b p
I hembyaffirm that there isa mnstmctlon lending agency for the perform
Z anofthe work forwhichthermit u Issued(Sec.3097,Civ.C.) TOTAL: 3
U 0 I<nderb Nam ELECTRIC FEE
PLUMBING FEE /Q
IL F- Lenders Address QTY. MECHANICAL PERMIT FEE
O W Iodilytha lfuve readthiaappucanonand state thatthexbove Information MECHANGFEE G
S is correct.lagree to comply with all city and county ordinances and.galelavn PERMIT ISSUANCE FEES PAID:
W relating to building mmtruction,and hereby authorize representative ofthts
1— Z city to enterupon the awve-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemmity an d keep harmless the City of Cupertino Date RKeipt#
against liabilities,}idgments,rosmand expenses which may in anywayaccm¢ AIR HANDLING UNT'F(To 1,(IIXI CFM) $UBTDTAL: Q
agaiwtsaid Cntyi uenc¢ofths granting of this permit.
/�� p AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Signature o4•p-'B —(x-
8 PP Date IXHAUBT bI00D(W/DIKT) E
AID:NAZARDOUS MATERIALS DISCLOSURE
Will th¢ efinedbant the urc ruin ngompantoe, hapten le 9.I Zandous HEATING UNIT(TO 100,000 BTU)
material by the Cupenlno Murddpal Code,Chapler9.12,and the RCCei t#
1:11 Y and Safety Codle/�-�S1eNioon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant.ffuture building ompant use equlpmenl or devices VENTILATION FAN(SINGLE RESID) 1$$�ANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air PAID Qu a lity Management Dist rict7 BOILER-COMP PHP OR 100,!X*BTU) NSI®
Yrs No
have read the hJrV usmatdlais requirements u oder Cha pter 6.95 of BOILER-COMP 100,000 BN) CCD q .� ���r-a
the Glifomia Health&Safdy Code,Sodium 25505,25533 and 75534.1 SEP r /s 0
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT.
rnponsiblfity to notify the occupant of the mgo,rcment,which must be mM n
prior to issuance of Cedificate of Ocmps nry. City Of I unerti.,
Owner or author! agent pale
TOTAL: ISSUEDBY: IPL V —V�tY/
OFFICE COPY r