21518 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
Budin Pct Identification PERwT NO.
Building Address:
` r 21518
wnere came: one: A
CITY OF CUPERTINO-BUILDING DIVISION
Contractors N y k.N� APPLICATIONS/ PERMIT
Y A 0 BUILDING EMECIMCA4PLUMBINGMECHAMCAL CATEGORY CONTROL X
Architect/Englneen Lk.No:
•,QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addres¢ PERMITISSUANCE ❑ ❑ ❑
L ED CONTRACTOR'S DECLARATION
Ihereby affirro mthat that)a.ivisi licensed3ofthe Business
o(Chapter
ssions9de,and APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I-rachSection7000)of Dlvislon3 o(theBminessandProlesdonsCode,and my
LIormia in(u and dfect.
LlcenseCy came "Lic.XC-fes G! '
Date Contractor �jsp+i
ARCHITECT'S DECLARATION 201"1000 AMPS
N❑O❑ I understand my plana shall be used as public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA 5/SQ.FI.
Fi�eu Licensed Profeeelarul SIGNS ELECTRICAL
OWNER-HOLDER DECLARATION SPFGIALCItCU1T/MISC - (�
Iherebyaflmothat l am exempt from the Contractor's License law for the
(011owingmason.(Section 7MI-S,Business and Professions Code:An ct or
county which requlma permittecorutrue"er,Improve,demolfsh,ormpalr TFAIP.METERORPOLEINST.
a anystructure priorto its issuance,also requlreslhe applicant for such permitt0
ryE 4 U file a signed statement that he is licensed pursuant to the provlalora of the POWER DEVICES
EOu Contractor'sLicense Law(Chapter 9(commencing with Section 7000)ofDivi.
, slon3r(the Business and ProfessionsCode)arthat he it exempt therefromand SWIMMING POOL�LECTRI VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
POP¢5. ,pplicart for a permit subjects the applicant to a civil penalty of nM more than OUTLETSSWITCHESI7
�" O five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole NEW REST L E j SQFT. STORIES TYPE CONSTRUCTION
�^ compensation,will do the work and the structure Tenor intended or offered for
Ct -to(See.7044,Basics and Professions Code:The Contractors License Law
$ doesnotapplytoUNITS an owner of property who builds or Improves thereon,a OCC.—GROUP RFS.
who doessuchwork himself orthrough becovo employees,provided that sue
Improvements arenot intended orof(ered foreale.If,however,the building or TOTAL1. '
Improvement issold withinoneycaro(compietloM1theowner-builderwill have
tfQiurdenof proving that he did not build or improve for purposeofsale.). BI PERMIT FEE FIADD ZANP. APN
u{as owner of the property,am exclusively contracting with licensed P ANCE
contractors to construct the project(Sec 7014,Badness and Professions Code:
The Contractor's License Law don not apply to an owner of property who
Wilds or improves thereon,and who contracts for such p(ojern with a " RAIN& WATE TA)
cnactor(a)licensed pursuantto the Contractor's License Law. FLOWO T FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for thin reason
•
Owner Data RECEIPT#
DRAIN ROOP,A SANITARY Y N ,
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm[hat 1 have'a certificate of consent to self-Insure,ora FIXTURES TRAP SCHOOLTAX Y_ N_RECEIPTN
certlfinteo(Workeri Compemationlnsurancearamrtlfkdmpythereof(Sec. GAS F.A.SYSTEM-1W S
3800,Lab C.) PARK ITR Y N
Po11ryX RECEIGAS.F.A.SYSTEM-OVER (EA) M
Cnm any BUILDDINGING DIVISION FEE
# S
Certified copy is hercbytthe
iGREASE/INDUSfRL WASTE IN PLANCHECK FEE
❑Certified ropy V(Tied withh tM city
ty inspection division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2t0FT DatC RCCeI t#
Hism
hction need net becompleted If the permit Bier one
(Drone hundred dollars
($i Wrdify t.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
I cent that in employ
he anyperformanceoninan oftheweekso as to li this
eorn permitI.booed, —
1 shake not employ any memos In any manner so as to become subject to the WATER SYSTTM/TREATING
Workers licanompensatlon Laws o(GII(omh. Date - PAID
O Z Applicant licen
Z O NOTICE TO APPLICANT:If,after nuking l his Certificate a(Exemption,you NEW RFSIDilJ1TA7,PLMB. SQ.6T. Date Recei t#
Fshould becomesabjed to the Workers'Compensation provisions ofthe Labor I TOTAL:
_N Code,you at forthwith comply Mth'such pmoialonsorthis permibhallbe
� � deemed revoked.
BUNG "
fLCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Ls a construction lending agency(or the perform, ELECTRIC FEE
TOTAL:
7 arcs ofthe work forwhichthb permit is boxed(Ser.3097,Civ.C.)
(> _ LIO
Lander.Name PLUMBING FEE
IL H LenderL aAddmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtify that l have read thbappliciahmand state thatrheabove Information
bmrrect.lagrn to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEE—PAID:
F- W relating to building construction,and hereby authorize representatives ofthls
H 2 city to enter upon the above.mentlorud property for inspection purposes. ALTFRORADDT'OMECH.
(We)agree to save,indemnify an it knp harmless the City of Cupertino Date Receipt#
V agalretllablll ,Ndgments,mdnand expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,OD0 CFM) SUBTOTAL:
agai try mmtxryen f the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX -
grutomofApplicant/Contractor to IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PA ID:
RATA R DOUS MATERIALS DISCLOSURE
Will the applicant orfuum building occo pant atom or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
.led.I as defined by the Cupertino Municipal Cade,Chapter 9.17,and the -
I lealth and Safety Code Section 25532(d? HEATING UNIT(OVER 300,000 BTU) OTAL: Oju
[3 Yes No
Will the applicant.4tom tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous all centamlwnts as defined by the Bay Area Air IYr�x q ��as
• Quality Management District? BOILER.COMP(3T0'OR 100,000 BTU) PEC V 19
4 Yes No
have read the haza ous materials requirements under Chapter 6.95 of BOHER.COMP(OVER IM,OM BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. yss
I ,�/ 6 r�IR
understand that if the build Ing does not currently have a tenant,that It h,my NEW RESIDENTIAL MECH. SQ.FT o f'""xHy
responsibility to notify the occupant of the requirements which must be met -
priortoissuanceof a Carti Ocate of Occupancy. � /j��
Owner or authorized agent Date ISSUED BY: V(/I1�YA.l../r""�s'�
TOTAL:
OFFICE COPY