21765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add .: f-I.Ms roR rD DR 21765
C r SP . CITYOF I IDIVISION APPLinKTr6R"9
AA
NamAPPLICATION
BUILDINGFLFiC1RICALI'LIIMBINGMECHAMCAL CATEGORY COND20LN
Architect/Engineer. Lk.No:
MY QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:�7 p�' '� I Y I PERMITISSUANCE El ❑ L-1LICENSED CONTR AC 'S ED DECLARATION
I herebyaffirm that l am license!under provisions of Chapter 9(commenc APPLIANCESRESIDENIAL JOB DESCRD'TION
ingwith Senlon7000)a(Divislon3ofthe Buairrssand RofessionsCode,and my
license Is In full force and effect. PANELS �L
License Clea Lk.A �L['�%"lI1sJ�'
Date Contractor L
ARCHITECTS DECLARATION 201-1000AMPS
flG I undehturstand my psh fl be used As public recess. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
nt OWNER-BUILDER DECLARATION
Ci 1'n SPECIALCIRCIRT/MISC
71' Thereby... Omtlam31.5.B fromthe Contractor).Code:t.tearew law fort he
(olbwing reason.(Semon 7071.5,Business and Professions Code:Any city or
F t'u� county which mquima permit tomnstroct,alter,terprove,demolish,orrepair
TEMP. OR POLE INST.
�Fl�.o anystructure priorto its Issuance,also requirestheappllcant for such permit to [OWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
3w Contractor's Licenselaw(Chapter9(mmmencingwith SeClon7000)of Divl- SWIMMING POOL ELE
O al
Mena of the Business and ProfeabvCode)or that he 6 exempt there(romand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
<$ appBcantfora permit subjects the applicant to a civil penalty of not more than OUTLETSSWITC Fl / BO.00
five hundred dollars($50M. NEW AFS[DENT[A ECT, G
�n ❑I,as owner of the property,or my employees with wages as their sole FL STORIES TYPECONSTRUCTION
compensation,will do the work,and the structure 6 not intended or offered for
O sale(Sec.7094,Business and Professions Code:The Contractors License law
$ does not apply to an owner of property who build.or Improves therm,and
F,S.. whodgemsuch work himself or through his own employees,provided that such OCC.GROUP
RES.UNTTS
Improvement.
are not Intended oruffered formic.If,however,the building or TOT
improvement ls wld within oneyearofcomplCio,nheowner-W Rderwill M1ave
mlenofpmving that he did not build orimprove for purposoofmk.). QTY. PLUM I PER T FEE FLOODZOM APN
A
s owner of the property,am exclusively con'n'ing wan Iicenad PERM SSUAN
tractors to construct the project(Sec.7094,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER WAtR(EAI
Wilda or Improves thereon,and who contracts for such IxWje with a
mt a (s)hmnwdpursuantmthe ContradoraLicena Law. BACK W OTECT.DEWCE FEE SUMMARY
IJ I am exempt under Sec B& P C for this reason
OUTSIDE FEES
Owner Date DRAINS K ROOF,AREA,COND. SANITARY Y N
WOR Kld N COMPENSATION DECLARATION RECE Pf a
S PER TRAP SCHOOLTAX Y_ N
❑1 hereby affirm that I have certi0rate of consent to oeuFTX'IVRE
re,or RECEIPT M
certificate C(Workers Compensatioo n lrsuranre ora reClfkd mpythpytM1ereof(Sec.
3gO3800,lab C.) CAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N
ry, RECEIPT M
CEMS ST
CgmCAFA.SYSTEM-OVER 4(EAJ
Y BUILDING DI VISION FEES
Certified copy is hereby Furnished. GREASE/WDUSIRL WASTE INTERCF7'TOR PLANC14ECK FEE
❑Ccrilied copy V filed with
the the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP IPAID
COMPENSATION SEWER-SANITARY-STORM FA.200FT. 5R9C Remi t#
Rhb section need not be comp)Tlithe permit isfor one hundred dollars
($100)orlea.) WATER HEATER W/VENT/ELECT, ENERCYFEE Y N
I cent employ
the pane,In ny he workmanner fo ax to become
permit 9 Lto theod, —
I shall not employ any Laws In any manner so a to berme mbject to the WATER SYSH9rt/TREATING
Workers Compenutbn laws of California.Date pplp
Z NOT[CApplicam NEW RESIDENTIAL PLMB. SQ,FT. Date Revel t#
Z z NOTICE 70 MPLICANT:I,after making thisCertificate of Exemption,you
should become subject to the Workers'Compensation provisions gfthe Labor TOTAL:
CC W Code,you moat forthwith comply with such provisions or this permit shall be ( UD
W > seemed revokBUILDINed.
CONSTRUCTION LENDING AGENCY SEISMIC FEEIhere1 0
7O(1 oofth woraffirmthat wlucheisammti ffon esseae(Ser.3gsng f.C.) perform ELECTRIC FEE
ancee,'A Nwork!or whkhthl.permit bLuuM(Sec.3097,CIv.C.) TOTAL:
LL Lender's Name PLUMBING FEE
LL F Panders Aaarea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertily ired.I that havemply sth Alicitynand dcounty oat rdinances and state
} IL isroingt building comply with andhereb authom reprceaatives slaw. PERMIT ISSUANCE FEES PAID:
W relatoenterupongegnstmctnamlor hereby property
or in represenpurpos ofthls
(— Z city(We)
a me to ave,he Indemnify An
property the Clan purposes. ALTER OR ADD TO MECH.
(We)agree to cove,Indemnify an d keep es which
harmless the City of CupertNo Date Receipt#
V
against Babllltin,Judgments,mrtsand expense which may in any wayamue AIR HANDLING UNIT CTO l0,000CFM) SUBTOTAL:
ag»nst C'ty In m e the granting of this_�
AIR HANDLING UNIT(OVER to,"CFM) CONSTRUCTION TAX
'ignatum of Applicant/Contractor Date EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HALA RDOUS MATERIALS DISCLOSURE
Will the appllorat or Fannie building occupant store or ha rad to hazardous HEATING UNIT(TO 100,000 BTU) Date RCcej t#
material as defined by the Cu Pontine Municipal Cade,Chapter 9.1 2,and the
Health and Safety Cod Bion 25532(a)2 HEATING UNIT(OVER 100,000 BTUI
F-1Yes �No TOTAL•
Willthe applicant or futurebuilding occupant use aqulpmenn ordevices VENTILATION EAN(SINGLE REBID) ]SgIIAhICF_pATE
which emit hazardous alr cont3Mm�ts as defined by the Bay Area Air �J.QA RILF-TJG'
(alfty Managcm:nt Distri{L7 BOILER-COMP(3FIPOR 100,000 BTU) p less o(�
4 Ye Ir�gN� JAM
hav'lead the hazy om erials requirementsunderChapter6.95of BOILER-COMP(OVE9100,000 BTU)
the Gli(ornla Health&Saf Code,Sections 25505,75513 and 25534. 1
understand that if the building doe am currently have a tenant,that it is my NEW RESIDENIIALMECH. SQF7
responsibility to net ify the occupant of the mryirements which must be tort _
prior to issuance of a Certificate of Occupa ncy. peps y��I}T^�j��Iln�
Owner or aulhoriud agent Date ISSUED BY-.
OFFICE COPY