21524 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
Building Id
Project B
flcaon - _ PERMIT NO.
Building Address; '
Oct 21524
ners arre
A A
L � we. CITY OF CUPERTINO-BUILDING DIVISION
.� Con--'.N.— yy��uallo: APPLICATION / PERMIT
JV.S BUILDING ELECTRICALPLUMBINC MECI-IAMCAL CA7'F-GORY CONTROL#
Architect/Engineer. Lic.No:A)k "
LCTR��PRIYIE - , LDING PERMIT INFO:
Ad TE ` AE
- -
PERMITISSUANCE r❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirrn that lam licensed un der Iain sof Chapter9(commene- APPLIANCFS�RESIDENTIAL JOB DESK ON
ingwith Secdon7000)of Divleion3ofthe8us etsan rofesslon.Code,and my
h
lienee le m(uu^ a effect. rMrE15
License Claes LIc.Xa /
Date Contractor dl._I
ARCHITECTS EC RA ON 201-1000 AMPS
0 COC I understand my plane shall be used es public records. OVRR 1000 AMPS SQ.FI'.FLOOR AREA $/SQ.FT.
ra�U Licensed Professional SIGNS ELECTRICAL Ay
<Zw - OWNER-BUILDER DECLARATION
I�o a Iherebyaf0rmthat Iexem)atfromthe Contractor's License Law for the SPECIALCIRCUIT ISC
Zp, sm
following reason.(Section 7811.5,Business and Professions Code:An ci r
'F f' countywhichmquWreapermittommtmdalter,impmve,demollah,orrepair TEMP.Mhz"ER OR T.
anystrucure prlorto Its issuancealsorequirestheapplimntfwsuch pemohm
V file a signed stateroom that he V licensed pursuant to the provisions of the POWER DEVICES
' Ott1. Contractor's License Law(Chapter9(commentlngwith Section 70M)of Div i- SWIMbRNG C C
30.:71 slon3o(the Buslnessend Professbv Cade)orthat he Vexemptthere(romaod VALUATION'
the basis for the alleged exemption. Any violation of Section 7031.5 by any
6 applicantfor a permit aubjectsthe applicantto a civil penalty of not morethan OUTLETS FI
O five hundred dollars($500.
1,as owner of the property,or my employees with wages as their sole NEW RESI E 772 SQ.FT, STORIES TYPECONS'IRUCTION
7¢ compensation,will do the work.and thestructure E not intended or offered for
.p sale(Sees.7044,Business and Profesahms Code:The Contractors License Law
$$ - does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES UNITS
who dcessuch work himself or through hisown employees,provided that such
Improvements arc not Intended oroffered forsele.If,however thebuilding or TOTAL:
Improvementswldwithinoneyearofcompletion,theowner-bullderwiilhave . "
tt�urd
en ofpmvingthat he did not Wild m improve for purpose ofsakJ. jjTy P[iUA'IBING PERMI'IT FEE,' FLOOD ZONE APN
u I,as owner of the property,em exclusively contracting with Iicenxd PERMIT ISSUANCE (^,('b
contractors to construct the project(Sec.70K Business and Profesuow Code:
The Conor
traeb 'a Ltcewe Law does not apply to an owner of property who ALTER- -
builds or Improves thereon, and who contracts fee such pkojects with a DRAIN&VENTWATER(EA) Qf�
c75actor(s)licensed pursuant to the Contranore License Law. Rp WPRO,I,ECT DEVICE FP E$UMMARY. ,
1_I I am exempt under Sec. B k P C for this reason
Owner Date DI NS FLOOI{ROO$,It@At:L N�, SANITARY Y_ N—
WOR KMAN COMPENSATION DECLARATION S'PER TRAP „� RECEIPT X
SCI.— TAX Y_ N_
111 hereby affirm that I have a certificate of consent to elf-Inwre,or a t
certiBcateof Workers'Compe®atlonlecuramem.cartifledwpythereof(Sea GAS EA.5Y5'TFM-1 IN OUTLETS,
RECEIPT X
3800,Lab CJ PARYM, Y_ N—
Poiicy# - RECEB a
C^,.,,,,ny 1 1 GAS �' BUILDING DIVISION FEES
ILrsyTy�alf)c_--'er[Ified copybhereby(urniahe GREASE/INDUSIRL AsrEI PLANCHECK FEE
ertified copy L filed with the city Impectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP Ale
PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT. Date Recei t#
(THo Icaa)n need not be completed If the permit V for one hundred dollars
($1I eadiless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ll am thatamp in oy an performance Pa..inan th workcanner forwhlcb co eermit issubjec Issued, —
Istall not employ any person In any manner w es to become subject to the WATER SYSTEM/TREAFlNNG -
Workers'Compensation laws o(Callfornla.Date PAID
Z
Z AppliNOTICE
NEW RESIDENTIAL ELMS. SQ,FT, Date -Remi f#
O NOTICE TO APPLICANT:IL after nki
ung this CertBlcete of Exemption,you
should tiecome subject to the Warken'Compevatlon provlslow o(the Labor TOTAL:
M Code,yourwstforthwlthcomplywithsuchprovislomorthiepermitshallbe
> deamednowked. BUILDING FE
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffirm that there is a construction lending agency forthe perform ,ry., ELECT-RIC FEE
M Z now of the workfor which this permit is lasued(Sec.3097,Civ.C.) TOTAL a ELECTRIC EEE
U 0- Lendera Name
ly F LendersAddreas QTY: MECHANICAL.PEWIT. FEET;' MECHANICAL FEE
O W I certifythatl have read thlssppli.terand statethattheabove Information
Iscorrect.I dgreetocomplywithallcilyand countyordinancesand statelaws PERMITISSUANCE - FEES PAID:
} a' relating tf3l;
Ilding cowtructlon,and hereby authorize representatives o(th0
W city to anpon the hove-mantle, dproperty far lwpectionpurposee. ALTERORADDTOMECH:
Z atisw Indemnify and keep harmless the City of Cupertino,jud manta,cwt and expenses whichmayinanywayacerue AIRHANDLINCUMT(T010,000CFM) SUBTOTAL'
c nsequence fthe granting of this permit
_ AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Sigruture Appl cam/Conn or Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDO MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as dented by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Cott ion 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes NO
Wllitheappllcant future building occupant use equipment or devices VENIILATION FAN(SINGLE RESID) ISSUANCE DATE
hich emit hazardous atr ntamiwnb as defined by the Bay Area Air
Qualuy Managemehe nt 7 BOILER-COMP(3HPOR 100,000 BTU)
4 Yea o
have read Health
a out mode,ls Section 25505,25533emorts aChapter.1 of BOILER-COMP(OVER 100,000 BTU)
the Cal rola Health kSafety Code,Sections 25505,25533 and 25534.1 ,
unders od'batl thebulldinKns=fthsrcqZ2'
emreave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
respo Ibility to re the Dements which must be met tj
Ari rt issu ce aCertificaOccupamy.
or auf oWd agent I ISSUEDBY:
TOTAL:
OFFICE COPY