21430APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm set Identification
BvRding Address:
PFRbIT NO.
21430
wnaOb1N M1eJeP' k:1 j&✓- ,?-53nZM(
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECnUCALPLUMBING-MECHANICAL
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CATEGORY
CON]RB---
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Archood/Enginaen Lt. N.
CITY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
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AddressPERMITISSUANCE
•. `�
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-RESIDENTAL
[hereby atfirmthst lam Bcensed under pmsislonsof Chapter9(mmmme
Ingwith Section 7000).!Dividon3 ofth.Busimmand ProfeulonsCode, and my
license is in fullc. and died.
License Clsss O Lk.« 50361i-
Deter( Contndor
JOB DESCRIPTION
(�
00;
PANE:
701 -TWO AMPS
ARCHITECT'S DECLARATIO
Iuodersumderyplawshalbeused u publlcmmrds
OVERI000AMPS
SQ. Ff. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
/ QO
L
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following mown.(Sedlon 7031,5, Business and Profmlons Code: Any city or
cmntywhkh mquims a permit tommtmd, alter, lmpmve, demolbh,ormpalr
SPECIALCIRCUIT/MISC
TEMP METER OR POLE INST.
anystmcture prlorto its Issuance, elan eequlrestheappllcant forsuch permit to
file a signed statement that he b licensed pursuant to the provlslo s of the
Contractor's Licerso Law (Chxpter9(commendng with Section 7000)of Dist.
don3 of the Buelneesand Pro(essiorsCode) .'that he b exemptthere(romand
the basis for the alleged exemption. Any violation of Section 7011.5 by anyb
the applicant to a civil penalty of nothan
applicant fora permit subjectsnor m
five hundred dollars (¢SW).
I, as owner of the property, or my employees with wages as their sok
POWER DEVICES
SWIMMING P00 ELECTRIC
CYT
.nano': SWITCH HkTl1RE5re
/
VALUA71
�I 'f
NEW RESIDENT[ ELECTR�Ff.
SCORIES
TYPE CDNSlRI1CnDN
compensation, will do the work and the simmare is not intended or offered for
-
aale (Sc. 7040 Business and Prof.fmv Code: The C.n ractdts Uses. Law
TOTAL:
does not apply to an owner a property who build. or improves thereon, and
wh.doess.d �rkhlmselforth=ghhisownemployees,provldedthatwch
Improvements are not Intended oroffemd for sale. If, however, thebuliding or
Improverrentissold within oneyearofcompldioMtheowner-buBderwlll have
OCC.CROUI'
RES.
tFAIZurden of proving that he did not build or improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to conslmct the project (Sec. 7064, Business and Professions Code:
The Contractor's License Law does not Apply to an owner of property who
W IWI or Improves thence , and who contracts for such plojects with a
cgp[fadons) licensed pursuant to the Contractor's License Law.
I_l I am exempt under Sec. B & P C for this reason
Qry, V PLIAING PERMIT FEE
'INN
J
70
& WATER (EA)
FLOODZONE
APN
W PROTECT. DEVICE
FEE SUMMARY
FLOOR R , A GOND.
FIXTURES PER TRAP
SANITARY Y N
RECEIT N
Owner Date
WORKMAN COMPENSATION DECLARATION
1 hereby affirm that I hive a certificate of consent to self -[dare, or a
rut areefWorkenn CompenaationinauranaorecedlFled copythereo
SCHOOLTAX Y_ N
RFGEIPf p
G�pA gy -) C.O ETS
PARK FEE Y_ N
RECEIPT N
3800, lab CJ -'')
11.111 Y 5 r r
GAS�EA. SY d ),
Coo ny_ &V
f5Cartmed copy Is hereby umis ed.
�Cedlfied ropy b tied with the city Inspection division.
BUILDING D I VISION FE ES
GREASE/ LWA INTERCEPTOR
PLANCHECK FEE
GREASE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thb wdlonneed nal be compiled lithe permit b forona hundred dollars
($100).'las.)
I nertify,that in the performance of the wok for which this permit b hewed,
1 hall not employ any person In any manner An as to become abject to the
Woru re Compenutlon Lawsof California. Date
APP
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
should become subject to the Workers' Comperuatlon pmvlsiou of the Labor
Code, you must forthwith comply with such provisions or this permit shall W
deemed revoked.
PAID
Date Remi tic
` " -
SEWER YSTORM EA 200F1'
WATER TER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Recei Nf
00pplicant
a
WATER SYSTLM/TREAnNG
TI
NEW RESIDENTIAL PLMB.SQFT.
TOTAL:
BUILDING FEE
SEISMIC FEB
CONSTRUCTION LENDING AGENCY
I herebyaffiruthat there is a construction lendlogagency torlhe perform-
ante of the work for which this permit As blued (Sec. 3097, Civ. C.)
TOTAL:
ELECTRIC FBG
Lendels Name
Lender's Address
IcertI. thatIlavereadthlsappBatlonand&atethattheabovedgateaaw
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QTY. MECHANICAL PERMIT . „FBE
PLUMBING FEE
MECHANICAL FEE .
FRGS PAID:
gate
Ie coned. building comply with andhereb muntyice
PERMIT ISSUANCE
relating to building mretwdlon, and hereby authorise representatives, oftws
of fhb
city Wenter Inspection
properly for Wpe Cit purposes.
eeupon to theabovemonify an
(We) agree to nave, an d keep harshen the City of Cu
ALTE20AADD70 MECH.
Date Receipttt
against sold City In Co rats, rasa which mayln anyway accrue
on, ..a
against said City in con ence of the ting of this pemdt.
AIR HANDLING UNIT (TO ID,000 CFM)
SUBTOTAL,
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
Igwmmof Appftca"nTM06tractor I Data
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,0DO BTU)
-
Will the applicant ortumre building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
IiealthandSafetyCode Section 25532(x)? -
Yes f�l No
Date RCCCI Tg
HEATING UNIT (OVER 100.000 BTU)
TOTAL:
s
VENTILATION VAN (SINGLE RESID)
IS MANCE DATE
Will the applicant orfnum building occupant use equipment or devices
which emit has Nous air mnla minani. as defined by the Bay Area At,
BOILER-COMP(3HP OR I OO,000 BTU)
Qua lily Ma nagement District?
qYet 9 No
have mad the haze nus materials requinmcnb urdarCh.ptr, 6.95 of
the Califernla Health & SafetyCoda Sections 25505, 25533 and 25534. I
T!
t
BORER.COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECFI. SQ.F..
understand that if the building does not cuently have a tenant, that it is my
mponalbllity, to notify the occupant of theonulremanb which must be mM
,
'
prior to Issuance of a Certificate of Occupancy.
ISSUED BY:YY'N��1i.KYJW �
Owner or authodved agent Data
TOTAL;
OFFICE COPY