21418 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ing Add ress: .. 21418
I IGO SL � ILS �WQ
t Owners Name: p one: -
w S B
O IRtin CITY OF CUPERTINO-BUILDING DIVISION I �� �
• Co cto . PLALlc,No: APPLICATION I PERMIT 1
�"' — `� L BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL M
Architect/Engimer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSIJANCE El 0'
•❑
that ILICENSED CONTRACTOR'S DECLARATION
IherebyaHirm that[ern licensed under provisions of Chapter 9(rommen A[rI7.IANCESRESIDENIIAL JOB DESC ON
maw'can Wslon3 ofth t 1 ea dProlesslons ,and my PANELS �1 �'��J R
license i and effect. �'�' ^V l R/ I
license �B
ale Contnctar UP TO 2DOAMPS
201-1000 AMPS
ARCHITECTS D R 1 N
cal understand my plans shall be used as public OVER 1010 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
E
Liconsed Professional SIGNS ELECTRICAL Om WNER-BUILDER DECLARATION
rn a SPFLIALCE2CNT/MLSC
71.,r�/ Iherebyaflrmthatlaexempt(mmthe CantractorsLketue Law for the
O following reason.(Section70315,Busincenand Professions Code:Anydtyor
requires;which requira permit to construct,alter,Improve,demolish,or repair ITMP:METIXOR POLE INST.
Ei
q� any structure prior to its Louis me,aW require the applicant for uch permit to
PJ O file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Q63O� Contractor's Liceree Law(Chapter9(commencing with Smmm7000)of Divi- SmiumiNG POOL ELECTRIC
Bfon3 of the Business and ProfessionsCode)orthat he is exempttherefromand VALUATION
Sn S the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHFSFIXTURES -
<
applicant lots permit sub"the applicant to a civil penalty ofnut=to'ban
five hundred dollars($500. NEW RESID• TR
�f F-11,as owner of the property,or my employees with wages as their sole SfDRIEq TYPE CANSIRIKTION
7a compemation,willdothework,and the structure is not Intended or offered for
O .1c(Sec.7094,Busurces and Professions Code:The Contractor's License Law
5$ does not apply to an owner of property who build,or improves thermn,and OCC.GROUP RFS.UNITS
who doessu le work himself orthrough his own employees,provided that such
improvements are not Intended or offered for sale.I(however,the building or
improvement is sold within oneyear ufcomplendom the owner-bulderwll)have
t"rdan of pmving that he did not build or improve for purpose of sale.). QTY, BING PERMIT E
FLOODZONE APN
LJ
I,as owner of the pmperty,am exclusively contracting with licensed P IT ISSU CE
contraction to commid the project(Sec.7044,Business and Professions Code:
The Contem or's License Law time no apply to an owner of property who ALM-DRAN A VENT WATER(EN (�
builds or Improve thereon,and who contracts for such projects with a FEE SUMMARY
11 ec.actors)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
LII am exempt under SB A P C for this reason
. Owner Date re
DRAINS.FLOOR ROOF,AREA,COND. SANITARY RECEPT#
WORKMAN COMPENSATION DECLARATION FIXT[IREA PER TRAP 'f eG, SCHOOL TAX Y N
[31 hereby affirm that I have a carti0cate of consent to self-mss ora 4�C/ RECEIPT R
3800,Lab C.)
carti(Icate of Workers Compemationlmurancoora certified mpythemof(Sec. GAS EA.SYSTEM•11NC4 �OUTLETS PARK - Y N
Policy s RECEIPT M
GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES '
Certified copy ts hereby fumished. CREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMff1ON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI' Date Remi [#
(Thissection need out be completed if the permit is forom hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certi(ythat In the performance of the work forwhich this permit is Issued,
I shall not employ any person many manner so as to become subject to the - WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PWB. SQJr. Date Recei t#
Z O NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you
N should become subject to the Workers Compemmton provisions of the Labor TOTAL:
Code,you moat forthwith comply with such provisoes or this permit shall be B
IRLDING FEE
W > deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il a Iherebyaffirm that there h a mmtruction lendingagency,forthe perform ,aseyy..�� ELECTRIC FEE
n Z anmoftheworkforwhkhthispermitisbs (Sec.3097,Civ.C.) TOTAL: NK/
Lender's Name PLUMBING FEE Q7
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certilythat l haveread thisapplicztionand statethatthe above information
1 u0mmct.l agree to complywith all city and county ordinances and orate laws PERMTTISSUANCE FEES PAID:
>. N matingto building construction,and hereby authorize representatives ofthis
F citytoenrer thea ve-mentioned property for impaction purposes. ALTERORADDT(IMECH.
Z Date Recei t#
_
against
a s vc n fy an d keep harmless the City of Cupertino
agalmt tiw Jud s,coxeand expenrn which may In ywayattrue AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
I i C1 coofthegmetles it pe
' /- AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Sigmtu p cat/Contract I Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
NAZARDO ATERIALS DISCLOSURE
Will the applicant or future ullding occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the m
Ilea lth and Safety C on 26532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: 14
❑ Yn
Will the applicant ot future building occupant use equipment ordevices VENTILATION FAN NNGLE RESID) -ISSUANCE DATE
which emit hazardous sI,contaminants as defined by the Bay Area Air �!.tJM
/i fM�
Quality Ma mgement t BOILER-CAMP(311P'OR 108000 BTU) P.,
M Vee
_• 4havc read thehaz ruamateriab requirements under Chapter 6.95 of BOILER-COMP(OVER Ife"BTU) ���� Du4�a�
the Cal4tf
h So C ,Sectlom2550S,2S533and25S34.I V 1 J
underste bu Ing a not currently have a tenant,that It ts my NEW RESIDENTIAL MECH. SQ.FTrespomBy a requiremantswhich must be meFri rto tBof Oc panty.
Ofmorroraubf6rl gunf Date,F
TOTAL: ISSUMBVw.
OFFICE COPY