21120 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY /'0•'[—'20
Building Project Identification P LFAJG _ PERMIT NO.
Building Address:
a 0 ;Z 1 ,Y/r,o I e ��-�— 20 21120
ours . aces: r n` ' one: HUN bUBMI 1-1 AL UA IL
CITY OF CUPERTINO-BUILDING DIVISION 10—+—qO
. "tr ar. '"a'�y,� a Lm. APPLICATION / PERMIT
I� BUILDING.ELECIMCAL-PLUMBING.MECFI LAICAL CATEGORY CONTROL p
Archlte n car. H G _ 3 6 6 LIa Nm
L l a QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: LICENSED CODECON
PERMITISSUANCE ar; ISI
I hereby effm,that lam licensed under provision.o(Chaater9
(mmmme APPLIANCES-RESIDENTIAL J00 DESCRIPTION
IngwlthScefon 7000)of DrAsion3ofthe BustnegsandP csslone Code,andmy
license le in fu and d(M. "; !./ PANELS
Lim LIc.R 3� Dom•/ Y�lJ4—
Dale �Conlractor
ARCHITECT'S DECLARATION 701.1000 AMPS
q�+�CO lunderstand myplaroshallbe used aspublicrectiNs. OVER IOOO AMPS SQ.Ff.FLOOR AREA $/SQ.Fr.
i4 0 0 Licenecd Professional SIGNS ELECTRICAL
H 6 OWNER-BUILDER DECLARATION $Pp-CIALCIRCUIT/MLSC 7 l� ts_a~ll('•/,1
L, � Thereby affirm thallam exemptfromthe Contractors Lianxlawfmthe
o following reason.(Section 74!15,Buslnmand Psnfmions Code:M tl or
O Z i.,a o ty TLMP.METFIi OR POLE INST.
P a` cauntywhlch requlrmaperMttommrequirstheimprove,dfr such,ormit to
any MrucWreprtwroit that nce,heir also iermcd urmant to the provisions
te POWERDEVICES
file a dens&statement that he V Ilanxd pursuant to the provlslom of the
Ow Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi-30<�<^ sion 3 ofthe Huntress and l'mfexlauCode)or that he b exempt therefromand SWIMMING POOL ELECTRIC VALUATION
S"^t the basis!or the alleged exemption. Any violation of Section 74415 by any QO
Da appkcant tura permilsubjMelheappllcanitoa dull peaulty&rat morethan OUTLETSSWITCHE&FI%TURES AQ tl
five hundred dollars($SM. NEW RESIDENTIAL ELFCIR vVv _L
I,an owner of the property, SQ.FT. STORIES TYPE CONSTRUCTION
p perry,or my employees is with ween as thele sole
e7Q compensation,w0ldothe work.and the,Code: hemat C.nttended Liceme Law
$ O sale(Sec.7DKpply Bu masers&Prooperty Code:The Contractors Lfmnse law
$$
dove mtappl work to an owner orthroug his own mporlmproovided eoryand OCC.CROUP RFS.UNITS
whodowaucFwarkhimxlf orthraugh Msownemployeee,provldedthat such
fmpmvemants are not intended oroffered for sale.If,however,thebufldfng or TOTAL: r
improvementinsold within aneycarofcomplMbNtheowner-builderwill have
tlrg urden of proving that he did net build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
1�
contractors to mrutruct the project(See.7044,Business and Professions Code: 1
The Contractors License Law time not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wild, or Improves lheamry and who contracts for such pto)ects with a
or(s)Banned pursuant to the Contra Roes Limnx Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B 6 P C for this reason
• Owner Date DRAINS-FLOOR ROOF,AREA COND. SANITARY Y N
ax. RECEPT M
WORKMAN COMPMNSATION DECLARATIONSCHOOL 7A% Y N
F11 hereby affirm that 1 have a certificate of consent to self-Insure,ora16% RECEB'I'M
certificate m Workers-Corepensztlon lwurance ora certified copy thercuf(Sec. GAS.EA PARK FIH? Y N
3800,Lab CJ
1'allry p GAS FA.SYSTEM-OVER 4(EA) DINGROZODf p
Co������mPPPPc y BUILDING DIVISIONITE$
Certified copy is hereby with
theh city
GREASE/IN PLANCHECK FEE
Certified copy V filed with the tlty inspection division.
CERTIFICATE OF EX EM PTION FROM WOR K ER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYEA 20OFT Date Recei t# (-4J/q4,ass
(Thi-section need n&4 complMed tithe permit V r
forore hundred dolla
($100)°`lees') WATER HEATER W/VENT/EI.ECTR ENERGY FEE Y N
I certlfythat in the performance ofthe work for wMch this permit is issued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ,7. Date Recei t#
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subject to the Workers'Compematlon provislone ofthe Labor TOTAL:
dk Code,you moat forthwith amply with such provisions or this permli,hall be s
> deemed revoked. G •E s
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perfmrm ELECTRIC FEE
0 ane of the warkforwhlch this permit is Word(SM 3097,Clv.C.) TOTAL: 4 ELECTRIC EEE
V lender's NameMIT
1L F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
IBM
O W Icertlfythatl havereacithisepplientfon and Matethallhe above lnlormat7on n atk�,
Is correct.l agree to comply with all city and county ordinances and nate law. PERMIT ISSUANCE 14� FEES PAID:
>_ (1 relating to building construnlon,and hereby authmbee representatives ofthb
(— N city to enter upon the above-mentioned peoperty for Inspection pu rposes. ALTER OR ADD TO MECH.
? (We)agree t save,fndemn an d harmless the City of Cupertino Date ReCCI t#
V against Uabll 10 Sonnets, sen nx ichmaylna wa came AIR HANDLING UNIT(TO 10,000CL'M) SUBTOTAL:
age ity In root t &this perm
AIR HANDLING UNIT(OVER Ig000CFM) CONSTRUCTION TAX
Ig reo( II t/Con rano` Data D(HAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOS RE �n
WllllheappllaIorfuture building occupa"tsture or handle hazardous HEATING UNIT CM 100,000 BTU) Date Recei t#
material as defined by the Cupertino Munldpal Code,Chapter 9.11 and the -
I leallh and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ye. M No
Wllltheappliant or future building occupant use equipment ordevices VENI7LATIONEAN(SINGLERESID) I Ie1G�E DATE
which emit hamrdous air conlarmeantsas defined bythe Bay Area Air LLQ O
• Quality Mawgement Di❑strict? BOILFR-COMP OHPOR 100,000 BTU)
4Yea have mad the hazarc onomaterials requtnewets under Chapter 6.95 of BOrLER-COMP(OVER 100,000 BTU)
the Califomiz Health k Safety Code,Sections 2S505,25533 and 75534.]
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT.
rmpomlbility to notify the occupant of the requirements which must be`ret gpyya�a}g4µA q
prior to Issuance of a Certificate of Occupancy, Sq Ig
W,4,,,lV�].s.�./�hJ,r'�'y�' `yam/-
Ow"cror.whorizedage"t Data 1. ISSUED BY: ^"`��VN.IFJ�`x"�•'V
TOTAL;
OFFICE COPY