21934 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
°andlogA°dm.: s 21934
sortee,. name one. A A
CITY OP CUPERTINO-BUILDING DIVISION0"101, Q f1
Cnntr Name: Lf 1' L-isc.No, APPLICATION / PERMIT U ,
�'COK T'lP+v CTC�S `'Z I l S BUILDINGELECTRICALMU BINGMBUH tICAL CATEGORY CO e L
FW Archit�m+/Engineer. Uc N. "�
9 K �1 BUILDING PERMIT INFO
QWELECTRIC PERMIT FEE
Address: ' I�4 PERM[TISSUANCE It
❑ ❑
UCENSEDCONTRA PIS
I hereby affirm that l am licensed under provisions of Chapler9(cmment APPLIANCFS-REMDEM'IAL
Ingwith Section 7000)of Divtsion3ofthe Businessand Pmfeaiom Code,and my
license Is In full form and affect. PANELS
Ltconse Class Lk.#
Date Contractor UP 10 200 AMPS
ARCHITECPS ECLARATION Wl-1000 AMPS
W, yndc�tapd m Ins B be us. b1/c remrys OVER 1000 AMPS .PLODR AREA /SQ.FT.
q��vv O t K �i y p �n j)'
k od� Licensed rofessioal SIGNS ELECTRICAL
fnalu OWNER-BUILDER DECLARATION SPECIALCETCUIT/MLSC
7��� I hambyaferm that l am exempt fromthe Contractors Limns.lawforthe
following reason.(Seaton 70315,Buaineas and Professions Code:Any city or
O� F m TEMP.METEROR POLE INST.
��� countywhich rNalm a permit toconstruct,alter,bnprove,dennlish,or repair
q 6 anystrucure priorto its issuance,also requiresthe applicant for such permit to POWER DEVICES
E5i U file a signed statement that he 6 licensed pursuant to the provisions of the
3 w Contractor'.License Law(Chapter 9(commencing with Seaton 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O stm3 ofthe Bwess
lnessand ProfionsCode)orthat he 6 exemptthercfromand
H SC' the basis for the alleged exemption. Any violation of Sectio7031.5 by any Q ^rY
Q 5. OUTLETSSWI7CHFSFl%'TURES lJ
appBant fora permit subjects the applicant to a civil Fealty of not more than Q
c. five hundred dollars($.500). NEW RESIDENTIAL ELECTR
�j.. 1,as owner of the property,or my employees with wages as their sok SQ.FE SCOW ES TYPE CONSTRUCTION
< compereatlon,will dothe work,and thestructure Is not intended or offeredfor
p sale(Sec.7044,Buslnessand Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or improves thereon,and 00C.GROUP RFS UNIT'S
who does such work himself orthrough his own employees,provided that such
improvements are not intended or offered for sale.If,howevep the building or TOTAL:
improvement 6sold withinomyearofcompletiogtheowner-W ilderwiB Wve
th rdenofpmving that he did not build or improve for purpose ofsole.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
L j L as owner of the property,am exclusively contracting with licensed a
contracto®to construct the pmject(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such pro)ects with a FEE SUMMARY
gWlactor(.)Ikenscd pursuant to the Contracor'a Llmnse Law. BACK FLOW PROTECT.DEVICE
c t�I am exempt under Sec. B&P C for this reason
OUTSIDE ITI'q
DRAINS OR FLOROOF,AREA,GOND. SANITARY Y N_
Owner Date RECEIT#
k I WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP, SCIi00L TA% Y_ N_
❑1 hereby affirm that I have a corticate of consent to sel6insure,or RECEIPT#
mroficate of Workeri ns
Compeation insurance ora cortified copythemof(Sec.
3800,Lab C.) GAS EA.SYSfEM-t INCA OUTLETS PARK FEE Y N
Policy# RECEE7#
Co Y GASEA.SYSTEM-OVER4(EA) BUILDING DIVISION PEES
Certified ropy Is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�. Certified copy 6 filed with the city 6upetatm division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID Q/ /`
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT. Date ReOCI t4 j(,s-c
(This section need not be completed lithe permit Is for one hundred dollars
($101B or less.) WATER HEATER W/VENT/FI FC.I.R ENERGYFEE Y_ N_
I mam
malty that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner m a,to become subject to the WATERSYSTEM/TREATING
Workcrs'Compensation Laws of California.Date PAID
OZ Applicant NEW RES DEN AL PLMB. SQFT. Date Rete) t#
Z O NOTICETO APPLICANT.If,after raking thin Certificate of Exemption,you
should become sob)ect to the Worker'Compensation provIsns loof the Labor TOTAL:
Code,you=at forthwith comply with such provisions or this permit shall W
FEE
W > destined revoked. BUILDING
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I herebyaffirmthat there is a construction lendingagency forthe perform- ELECTRIC FEE
Z arm ofthr workforwhichthis permit 6 Issued(Sec.3097,C1,C) TOTAL:
02 Lander.Nam PLUMBING FEE
LL I— Lcuders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEH
OO Icertify that l have read this application and date that theabove Information
a Ismrrea.Iagreetocomplywithailatyandmuntyordinancesande telaws PFRMITISSUA.tiCE FEES PAID:
} relating to building construction,and hereby authorim representations ofth6
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cu Fortino Date Receipt#
V against liabilities,pdgmen6,coSts and expenses which may in any wayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said;Citae.is caa�7:sgra nil (this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gat fAppiimot/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA BOGUS MATERIALS DISCLOSURE
Will the applies rt or future building occupant store or ha nd le hazardous HEATING UNIT(TO 100,000 BTU) Date ROtei t#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the'
I lealth and Safety Code Section 75532(a)t I IEATING UNIT(OVER 100,000 BTU
Yes r]No .
Will the applicant orfutvre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE
which cont hazardous air mots mlardsa.deo ned by the Bay Area AU JUL, r
ality Management District? BO[LER-COMPpM'OR t00,IXO BTU 6
Yes No
have read the haze ous materials requ lmments a oder Cha pter 6.95 of BORER-COMP(OVER 100,000 BT U) �
c California Health&Safety Code,Sections 35505,35533 and 75534.1
u nd ersta nd that if building does not currently have a tens rt,that it is my NEW RESIDENTIAL MECH. :Q.17.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
I
Owner or authorized agent Data TOTAL: ISSUED BY:
X-
OFFICE COPY
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