21097 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PFRMH NO.
Oullding Addree , 21097
ners n fit+ one: p
Jv �a.l--G�� CITY OF CUPERTIN0.6UILDING DIVISION
G Ira nr.N: Lk.No: APPLICATION / PERMIT I t-I3—'40
l BUILDINC-MFICTRICALML BINGMECHAMCAL CATECARY CONTROL N
Architect/Engfneee Llc.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMIT ISSUANCE ❑ El 1:1ISI
LICENSED CONTRACTOR'S DECLARATION u
I hereby dio Irmthat lam Bammd under provlatuffre ofChapter AI'PLIANCESRESIDENTNL JOB DESCRIPTION
Ingwith Sectlon7000)and ellsmn3a(Ihe Buelnedsand PmfeesloneCode,and my ��,
license is in full rce and etfce. PANELS
License Clam Lk.M a Z
Date Contractor 201-1003UP TO2 AMPS
00 AM
ARCHITECTS DECLARATION
02. I understand my plans shall be used as public records. OVERIWOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
u�L�j Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPLCIALCI4CUfT/MLSC
pH Iherebyaffirm that famexempt from the Contractor's License Law fee the
QQ following reawn.(Sceion7m15,B.Muemand Pmfenioos Code:Any Mtyor
FE'cy muntywhichrequimapermitwcomtmc alter,impmve,de=lbh,ormpair �MP.METQt OR TOLE INSf.
� .77any structure prim to Its issuance,alsomqulresthe applicant for uch permit to
S'r 5 file a signed statement that he b,licensed pursuant to the provisions of the POWER DEVICES
O3 u, Contactors License Law(Chapter9(commencingwith Seeks 70111 of Deal, SW1MMNG POOL EL
1„ 01 km3.fthe B.smeasard ProfrosionsCode)orthal heboxempttherefromand VALUATION
g O the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEISSWIIC IS
�j Cd?v epplicaut for a permit subjectsthe appllcanito a civil penalty of not more than
E $ flue 1.as
demidollarthe property,
Rp�D E TR SQ,FT, STOW GS TYPE CONSTRUCTION
�n ❑I,as owner ll the property,or my employees iii with wages as thele dole
compensation,Beef..,adothe nd
andlhe structure Th cwt Intended or offered for
O sole(Sec.7ply to Beef..,owand Professions Code:The Contractors License Law
�$$ dont not apply roan owner ofprough Nson empor improoes yees,povidedreon,and OCC.CROUP RIS.UNITS
who does
mentsawork himself edoroffe Maownemployem,provided such
Improvements arenot intended oro((ercd(orsak.If,howeve,IheW ki gor TOTAL:
ImpmvementhsoldwithlnoneyearofcomplMlogtheowner-builder lilhave
t rdsn of proving that he did not build or improve for purpose of 16J. QTY. PL G PERMIT FEE FTOOD ZONE APN
[as owner of the property,am exclusively contracting with ti sed
mntactoatomwtr dthepmject(Sec.70M,Budbe and ProfemlomC' e: TT CE -
The Contractors Llcenx Law does not apply to an owner o<property o AL -D I & -W
Wild.or improves theorm,and who contacts for such p(ejects with
�'<}fljtecmr(s)IkensM pursuant tothe Contrictorf Llcenm Law. BA PROTFL E FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason
•
GRAINS. A COND. SANITARY Y N Owner Dace RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES SCHOOL TAX Y_ N_
I here)ry affirm that I have a certificate of consent la self-Insure,ora RECEIPT p
Iflateof Workena pewatioeiruuranceora ceAlfW copythermf(Sec. GAS EA 11C.4 O PARK FIT. Y N
W,lab C. Q
Poliryp - 131 �_ CAS EA. Sf'FM- VER4 ) RECEBPTN
on any >/- BUILDING DIVISION FEES
�Certi(le copy is hereby te city
d copy is filed with
the ccity inspection division. GREASE/INDUSTRLW INTER(7"TOR PLANCHECK FEE
fenitle
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANT -STORM EA 2001117. Date RCL-el t#
RM 'eneed not Mcompleted Ifthe permit Vfor orohundred dollars
a100)orlemss.)J WATER W/VENT/ELECTR ENERGY FEE Y N
Iartify that In the performance of the work for which this permit labored, ' N—
I shall not employ any person In any manner an as to become subject to the WATERS STEM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant Date Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW DENTIALPLMB. SQJT.
should become sub ect to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions or this permit shall be
j deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffirmthat there b a construction lending agency for the pekomnry ELECTRIC FEE
Z anreoflheworkforwhlchthispermltbbdued(Sea.3097,CIv.C.) TOTAL:
02 Lender's Name PLUMBING FEE
U. F Lender's Address QTY: "MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythallhave read thbappllationand Matethatlheaboveinformatian
(L Idrorrect.I agreeto comply with all city and county ordinances and Mate laws PERMITISSUANCE 1Z,CO FEES PAID:
} U) relating to building construction,and hereby authorize representatives of this
F- Z city to enter upon the aboverncmloned property for Inspection purposed, ALTER OR ADD TO MECH. Date RCCCI t#
_
(W)agroc to my Indy an d keep harmless the City of Cupertino P
aga' Ilablliti ,p nI=.and expenen which may In any EYNvaccrue AIR HANDLING UNIT QO10'"CFM)
SUBTOTAL:
a sad In ne uedceo(lheg :rx aa(tI pe
rh q9()_I AIRHANDI.ING UNIT(OVER 10,(MCFM) CONSTRUCTION TAX
Blgeatumof Ap nt/Contractor .. DM — EXHAUSTHOOD(W/DUCT) CONSTRUCTION T=PAID:
ZARDOUSMATERIALS IIISCLOSURE ,Willtheapplicant or future building occupant store or handle hazardous I'HEATING UNIT(TO IBILOOO BTU) Date
material as deft ned by the Cupertino Municipal Code,Chapter 9.17,and the — -
IIvalthand Safety Code Section 25537(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL' em
Ej Yea t]No
Will theappllcanl or future building occupant use equlpment or device, VENTILATION FAN(SINGLE RESID) llpN('E DATE
which emit hazardous air contamlwnta as defined by the Bay Area Air ��Rf}LY'7S
• Qu bty Management District'! B0ILER-CDMP(3HPOR 100,M BTU)
[?Yeen❑No g1A s)
have mad the harJO:.tekb amquiremonts under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) V 1 990
understand the California Health&Safety Cod,Sections 25505,25533 and 25534.1
understand that lithe building does not currently have atenanp that it is my N'EWRESIDENTIAL MECH. SQ.P•I',
responsibility to notify the occupant of the requirements which most be met4{,y's.'r,� �1
prior u i•'to Lssua nof a Certificate of Gnu pa my.
Owner or authorized agent Data [^r '�..e Le.a�nlJaia•1
' TOTAT ISSUED BY:�
OFFICE COPY