21021 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification - PERMIT NO.
Budding Address: 7 �� /kL�1 f �� 21021
nerµ�f'l6l Vf k Y 9/� 255 phone:�11i (2- D
CITY OF CUPERTINO-BUILDING DIVISION Cj
c.^tractors amen - Lie.No: APPLICATION / PERMIT
""1 HMLDING-FLECTRICALPLUMBING-MECIIAMCAL CATEGORYCONTROL It
Archlted/Engineer. Lk.No: '
'Q'n;;'.;. '" ELEC,T1 " PERMIT t •''`=,FSE" BUILDINGEERMIT'INFO;;'
Address: 11 1
PERhHTISSUANCE ❑ 11 11LICENSED CONTRACTOR'S DECLARATION LLjJ
wl ffiS crcm mthat l am licenssirm3ed undersinew ,11're Chains 9(code,and nc- APPLTANCESRESIDEMTAL ]08 DFSCRH'TfON
Ing with infuliforecafd effeon3 ofthe8ueinessand Pro(eadona Code,and my -
licenselein(uBforceandeffect. PANELS ,�—
L,...Clam Lie#
Date Contractor UP TO 200 S
ARCHITECTS DECLARATION,, 201-IMOAMPS
O Z I understand my plans shall be used as public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA , $/SQ.Fr.
q�0O
j�z Licensed Protesslowl" - SIGNS ELECTRICAL
6 .OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
.7 Ihercbyaf(Ime that l am exempt from the Contractor's License Law for the
p oo following reason.(Section 7031.5,Business and Professions Code:Any city or
.0ZI"' countywhich require.a permlttocorutruct,alter,Improve,demolish,orrepalr TEMP,METERORPOLEINST. ,
anystructure priori.it.lswaKe,also requireathe applicantforsuch permit to POWER DEVICES
file a signed statement that he 1s licensed pursuant to the provisions of the
Contractors License Law tCha er9(comerencin with Section 700D of H ) SWIMMING I'(lOL ELECTRIC
Won 3of the Business and Professions Code)arthat he is O exam therefrom and VALUATION the basis for the alleged exemption. Any violation of Section 7W 1.5 by any OUTLETS-SWIT'CHFS-FIXTURES
applicant fora permit aobj%uthe applicam to a dvil penaltyof not morethan 3 oQ�
QQ
five hundred as
ewnerof the property,
SQFT. STORIES TYPE CONSTRUCTION
R Iu NEW RESIDENTIAL ELECTR
Z¢ c❑I,asowneroftheproperty,orhe employees with wages rtheir sale
compensation,Business
uldotheworkandthes Code:
nor Intended or offend for
O sale(Sec.apply
Bu sinessandf property Code:The Contractors themes Law
�'j S does not apply to an owner of property who Wilda or improves thereon,and OCC,GROUP RES.UNITS
who doessuch work him ealforthr.ogh his own employees,provided that such
Improvements are not intended oroffered for sale.If,however,thebuilding or L:
i provereentissoldwithin oneyearofcompldioo.theowner-WBderwillhave , ,
it purden of proving that he did net build or Improve for purpose ofsak) QTy; ^ •(PL1I]V1BIN(i'ITER IT • '� -E.'- FLOOD ZONE APN
1�1(}�I,in owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
c nt=don to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER W-1)Wilds or Improves thereon, and who contracts for such p lejede with e
,,00tt�[[ador(s)Hm^sed pursuant tothe Ccenractor'.License law. ..FEE.$UMINARY .
TJ I am exempt uOu
nder Sec. e&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND, O SANITARY Y N
• Owned s Date RECUR'T'p
ORKM I PENSATION DECLAR 1 �,�S PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o certificate of consent to copy
theree ora RECEIPT If
3800,Lcertificab of Worken'ComperoaHon Insurance oracerti(kd copy thereof(sec. CAS G.SYSTEM-1 INC.40UMET5 PARK FEE Y N
330Q rob C.)
I'ollry p RECEGAS G.SYSTEM-OVER 4(G) DING DI p
Com any BUILDING DIVISION PEES
❑pCertified copy b hercbyth the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑CertHled copy la(Iles with the city inspection divlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM G.200FT. Date Remi tM
(Thlssedlon need not be completed tithe permit b for one hundred dollars
($1I comlev.l WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertl(ythat In the performance of Nework forwhlch this permit is issued,
Ishall not employ any person in any manner eo u to become subject to the WATER SYSTEM/TREATING
W.rkers'Compensation laws o(GIt(.rnla.Date PAID
O Z Applicant NEW RESIDENTIAL ELMS. SQFI'. Date Recei t71
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you mu at forthwith comply with such proNslore or this permit shall be
LU j deemed revoked. BUILDING FEE
W
d G CONSTRUCTION LENDING AGENCY _ - SEISMIC FEE '
]hereby affirm that them is a construction lending agency for the perform ELECTRIC FEE
Z anceoftheworkforwhlchthlsperrnitlsissued(Sec.3097,Civ.C.) TOTAL
V O. Lender's Name - PLUMBING FEE
- Lender's Addreas QTY. :', .MECHANICAL PBRMIT FEE
O W Icertifythatl havereadtMaapplicatlonand ststethattheabove Information MECHANICAL FEE
1 is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives ofthld
Zcity to enter upon the abovcmenHuned property for inspection purposes. ALTER OR ADD TO MUCH.mDate RCCCIp[?f
_ (We)agree to save,Indenify an d keep harmless the City of Cupertino
against liabilities,judgment.,cons and expenses which may in anyway same AIR HANDLING UNIT CFO 10,000 CPM) SUBTOTAL:
a t said City I conscryenre f the gran eg of this permit.
e. AIR]iANDWNG UNIT(OVER tO,WOCFM) CONSTRUCTION TAX '
grmtoreof Applicant/Copra Cc g� EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant orfuture building occupant store or handle hazardous - HEATING UNIT(TO 100,000 BTU) Dale Recei (�
material as defined by the Cupertino Municipal Code,Chapter 9,12,and the -
Health and Safety Code Section 25532(a? HG77NGUMT(OVER100,0110BTU) TOTAL: ly,40
❑ Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 'ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(311POR 100,0W RTU)
4 Yee 9 No ff 1111
have madthehaza ousmatedalsmquirementsunderChapter6.95of - BOILER-COMP(OVER 100,D00 BTU)
the Califemla Health&Safety Code,Sections 25505,25533 and 2x534.I r�
understand that if the building does not corrently have a tenant,that It is my NEW RESIDENTIAL MUCH.' SQ.Ff. - SEf�j 2 IJ.7p(�
7U
responsibility to notify the occupant of the requirements which must be met
prior to lssuarm of a Certificate of Occupa try.
Cty fGj(RRI'hQR
w
Onerorauthoriad agent Date ISSUED BY: Y bl U
TOTAL:
OFFICE COPY