21554 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMM]T NO.
Building Address: CL/ / 21554
:Z D$(Ps' Ac fJ /JA 14Z ,
Front: A A A
w :4C 4xS . V. T)f S ✓O CITY OF CUPERTINaBUILDING DIVISION _YO n
=entractoraNaor: Lm.No: APPLICATION If PERMIT Z C V
f = L=rz, BUfLDINGaECTRICALMUMBINO-MECHAMCAL CATEGORY CONTROL N
Architect/Englneee Lic.No:
QTY ELECTRIC PERMIT. FEE'. - BUILDING PERMIT INFO.:
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION MPLIANCESRESTDENTIAL
I hereby affirm that l am licensed under provisions of Chapter 9(comment ]OB DESCRIPTION
ingwith Svdur7000)of Division3 oftheliusinessand PrefesslonsCocie,and my
cense Is in full forte and offers. 2 zz fy 3 � PANFIS / �p
Late Ci'=V- C nhactar d (-1 A 1f --v GV
ARCHITECT'S DECLARATION 201-1000AMPS
�'� lunderstand my plarushdl be used a public record. OVER 1000 AMPS SQ,Fr.FLOOR AREA $/SQ.FT,
O
U E Licensed Professional SIGNS ELECTRICAL
�Z. OWNER-BUILDER DECLARATION
Iherebyafflrmthatlamexemptfmmthe Contranors Licenselawforthe SPECIAL CIRCUIT/MIST
TEMP.METER OR POLE INST.
jO"— following reason.6ection 7061 S,Business and Professions Code:My city or
]E' countywhlchrequtresa permitWcomtmn,alter,impmve,demollsh,ermpar
anystrodure prior to its Issuance,also requlrestheappilcantfor such perm)tto POWER DEVICES
file a signed statement that he Is,licensed pursuant to the provisions of the
Contractor.License Law(Chapter 9(comonencing with Section 7000)of Divi- S1ypt{hgNG IDOL EIECIRTC VA UATION
OS the bawen slon 3 ofthe Business and Professions Code)orthat bels exempetherefromand
sy
ls for the alleged exemption. Any violation.(Section]m15 by any
OUTLETS-SWITCHES-FIXTURES SD _
sm� appilcant for a permit subjects the applicant to a civil penalty of not more than
Bve hundred dollen(SSOW. NEW RESIDENTAL ELECTR SQ,HT. STORIES TYPE CONSTRUCTION
n ❑Gas owner of the property,or my employees with wages as their sole
t:q2 rompemation,wllidothe work andthestrunurelsnotintendedorotferedfor
'0 sale(Sec 7066,Business and Ptofessi..Code:The Contractors License Law
don not apply to an owner of property who builds or improves thereon,and OCC.GROIIP RES.UNITS
who don such work himself or through his own employees,provided that such
Improvements are not Intended cluttered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearo(completlon the owner-bu Oder will have
N,�arden of proving that he did not build or Improve for purpose of sale.). QTY, '` .,PLUMBING PERMIT - - , FEET FLOOD ZONE APN
L_j L as owner of the property,am exclusively cantracting with licensed PERMITISSUANCE
contractors to construct the pmjen(Sec.7064,Business and Professions Code:
The Contractors License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilda or Improves thneon,and who contracts for such pCo)eCts with a
�q➢t(adolls)licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE FEE'SUMMARY
L�I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RFCm
WORKMAN COMPENSATION DECLARATION }-IXNSPER TRAP SCIiOOL TAX Y_ N N_
❑I hereby affirm that I have a certificate of consent to self-Nwm,ora RECEIPT N
cenificateofWorkeri Compensation Insurance or.certified copy themcf(Sm. GAS EA SYSTE 4WG40UTLETS PARK FEE Y_ N
3800,lab C.) RECEIPT N
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Co any
fCertled copy 6 hereby famished. CREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertified copy Is filed with the city Inspection division. le-
CERTIFICATE
eCERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANH'ARY-STORM EA.200FI', Date Remi t#
(rhlssedion need not be completed tithe permit lsfor one hundred dollars
(SIM)or less) WATER HEATER W/VENT/ELECIR ENERGYFEE Y_ N_
I e tify that N the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers Compensation laws of California.Date
O Z Applleam NEW 1261DENTIAL PLNB. SQ}T. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should beconr subject to the Workers'Compensation provisions of the Labor TOTAL:
F" N Code,you nwstfonhwithmmplyw(thsuchpmv ioroorthIs permitshalibe BUILDING E -Z . ad7
jdeemed revoked.
CL — CONSTRUCTION LENDING AGENCY SEISMIC FEE a
CL I hereby affirmthst there is a construction lending agency for the perform, TOTAL: ELECTRIC FEE
� Z secs of the work for which this permit is issued(Sm 3097,Civ.C.) PLUMBING FEE
QO Lcndns Name
LL F Lenders Addnv QTY: :,'•MECHANICAL.PERMIT . ,,.FEE"- MECHANICAL FEE
O L) I¢nifythat l have read thlsappilration and state thattheabove information FEES PAID:
umrnct.lagree to comply with all cttyaM county osdinancn and gate Iowa PERMIT ISSUANCE
1 relating to building construction,and herby authorize representatives of this
Z n to emeru caths above-mentbned for Inspection ALTEROR ADD TO METH.
.ty Pon propertyparpose•, Date Reeei t#
(We)agree to save,indemnify an d keep harmless the City of Cu Pen Ino AIR IiANDIIhIC IP.xTT CTO 10,000 CFM)
V against liabiDtlea,)adgmenb.consand expenses which may In any waya_e SUBTOTAL:
against t Inco of the -ming of this permit AIR HANDLING UtJR(OVER IO,ODOCFM) CONSTRUCTION TAX
ignature car local enmr car �l a EXHALFr HOOD(W/Dlxn CONSTRUCTION TAX PAID:
HAZARD USMATERIALSDISCLOS RE ' FTFATING UNTT(TO1W,W0 DN)
Will the applicant or future building occupant store or handle hazardous Date Recel t#
outcrial as defined by the Cupertlno Munidpai Coda Chapter 9.12,and the
Health and Safety Code Section 25532(.)7 HEATING UNIT(OVFR I0Q0M BTU) TOTAL: _
❑Yrs �]No VENTILATION PAN(SWGLE RFSIW ISSUAAK�OATE
Will the applicant or future building occupant use equipment or device E��//''�����O�IN
which emit hazardous air contaminants as defined by the Bay Area Air BOILER-COMP OI-I'OR 100,000 BT(A
Quality Marugerrrnt District?
4Yn ❑No BOILER.COMP(OVER IM,D00 BM Llf,G
hrvereadNeFu rdousm tc a6 qui m nnunderChapter6.95a!
Ne Glifcros Health k SafetyCode,Sections 25505,25533 and 75536. 1 NEW RESIDENTIAL METH. SQ.ET.
understand that if the building does not currently have a tenant,that It is my ss}
responsibility to notify the occupant of the requirements which must be mat (:U-'(11110
prior to issuance of a Certificate of Occupancy
Ownerurauthorlaxdagcnt Date TOTAL: ISSUED BY:C�1 L+C�`Iw�"�l�-!✓l
OFFICE COPY