21258 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
Building Project Identification PQIMTNO.
Building Address: s - C
b Gtr- J
vers arae. one: A A
CITY OF CUPERTINO-BUILDING DIVISION
Contractora Name- Lie.No: APPLICATION /PERMIT
�..LJSL/ I4— C l -383 3 Bl,'ILDING-ELECTRICALPLUMBINGMECHAIv7CAL CATEGORY CONTROL#
Architect/ ginner. Lk.No:
QTY ELECTRIC PERMIT FEE .BUILDING PERMIT INFO
Address: PERMITISSUANCE r� ❑ `r ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Lf�
I hereby affirm that l am Reassert under provisions of Chapter 9(mnuncre. APPLIANCES-RESIDENTIAL- JOB DESCRIPTION
ingwlth Sedion7000)of DIAs on3ofthe Businemand PmfmionsCode,and my
to...is in hall 150
Ind effect.
Licens�'CI v a-,Wv Lie.# 3 S� P��
Date11 a��-fContraRor 4t.JI-J
ARCHITECT'S DECLARATION 201-1000AMPS
M ZO I understand my plans shall be used as public race s. OVER 1010 AMPS SQ.FT.FLOOR AREA $/SSQ.FT.
.60 Licensed Professional SIGNSELECTWCA
<Z
�¢ - Om exempt from
DECLARATION SPECIALCIRCUfT SC
I—
I hereby afRrmthat[axemp[fromthe Contractor's License Law for the
O 9). following reason.(Section 7alIS,Bwlnm and Professions Code:Any cityor TEMP.METER OR [N
u9 countywhichrequimapermlttowmtmct,alter,impmve,demolLah,arrepalr
F ,�J� any stmdvreprlorto its Lswance,aLso rcqulreatheappllant Tor such perMtto POWER DEV]
O U file a signed statement that he is licensed pursuant to the provisions of the
83q� Contractors License Law(Chapter 9(commencing with Section7000)ofDivi- SWRAAgNG C S VALUATION
O sion3ofthe Businessand Profmiois Code)orthatheuemm themfromand the basis for the alleged exemption. Any violation of Sectio70115 by any E.�SWI
appllant for a permit subjects the applicant to a civilpevlry,d not mare than
0. o five hundred dollars(¢500).. W ESLD E .FT. STORIES TYPE CONSTRUCTION
Z 6 (,as own
compr of the property,or my employees with wage as their sole
compensation,willdo the work andthe structure is not intended oroffered for
$ ❑ sale(Sec.7614,Rusinesa and Profmions Code:The Contractors Lkense Law
docs not apply to an owner of property,who Wilds or improves thereon,and
^ whodoessuchworklumsel orthrough hisownemploym,provided that such - OCC.GROUIs RFS.UNITS
improver ntsarenot Intendedoroffercdfwsale.If,howeverthebuilding or OTAL:
Improvement issold within one ycarofcompietion,the owner-bulldcrwlll have
thp*adeno!proving that he did not Wlid orimprove for purpose of sale J. QTY. ' LUMBINGP T FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractor.Llcenee law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffN
Wilds or improves therses,and who contracts for such projects with a FEE SUMMARY
m1��odor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINFLOOR,ROOF,AREA,GOND. SANITARY Y - N
• Owner Date S R, RECQITN
WORKMAN COMPENSATION DECLARATION FIX.IURE&PER TRAP SCHOOL TAX Y_ N
❑1 hereby affirm that I have a cere
rtlRote of consent to self-Insure,ora RECEIPT X
motficate,ofWorkera Compensation Insurance or a certified copythereof(Sec. GAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N
3800,Lab C.) REC�'T X
Co11ry X GAS EA.SYSTEMOVER 4(EA) BUILDING DI VISION FEES
Cany
Milified ropy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city inspection division.
CERTIFICATEOFEXEMITION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20017.
(this section need not be completed If the permit isfor one hundred dollars Da[C Remi t#
(s100)orim.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in me performance of the week fee which this permit is issued,
T shall not employ any person In any manner m as to Wcor�a s�bgR to the WATER SYSTEM/TREATING
Workers'Compq,satlonlawsof lifermyJ�a.Date 8 m-7-11i PAID
O Appliean'` ��w/ Date Recei t#
Z NEW RFSIDFMIAL PLMB. SQ_FT.
Z O NOTICE M ttothe orlursakomper tion pro is Exemption,you
should brxome subject to the Worker'Compensation provisions of the Labor TOTAL:
N Cees,you at farthwuh comply with such provisions or this permit shag W BUILDING FEE
deeed revoked.
W > mCONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I herebyaffirm that there h a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z ante of the work for which this permit is isseed(ser.3097,Civ.C.) PLUMBING PGE
V O Lenders Name
LL F Lenders Addreas QTY. MECHANICAL PERMIT FEE
OW 1mrti(ythatl have read this applicationand statethat theabove information MECHANICAL FEE
S eicorrect.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ 0. to building construction,and hereby authorize representatives ofthes
I— N city to enter upon the above-med entionproperty for Inspection purposes. ALTER OR ADDTO MEGH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReCeIPt#.
V ago Wt Rabilltks,judgments,costa a od expenses which may in any way accrue AIR HANDLING UNIT(TO 10,010 CFM) SUBTOTAL:
ga inat said City in conser once of the gram ing of this permit ,
p AJ AIR FLA LI OMT(OVFR l0,000CFM) CONSTRUCTION TAX
�
SA��AL.AAn," �°r CONSTRUCTION TAX PAID:
Slgrotu (Applicant/ retrz or Date EXHAUST HOOD
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 932,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER IW,000 BTU)' TOTAL: Ll-ttbo
MYes Mole _
Will the applicant or fuumbuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit banrdous air contamimnts as eleMed by t W Bay Area Air
Quality Management District7 BOILER-COMP PFR'OR 100,00 �a
BTU) s
Yes F-1 No
a11f(J
4havercadthe hazarlousmateriabrequirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sectiom 25505,75533 and 25534. 1
understand that if the building does not mrmntly have a tenant,that it is my NEW RESIDENTIAL MECIL SQ.FT.
responsibility to notify the occupant of the requirements which must be rrct
priorto(nuanceofaCertificateofOa panty. fly,
nl I.
Owner or authorized agent Data TOTAL: ISSUED BY.
OFFICE COPY