21341 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMITNO.
Building Address: 21341
Owners r9amcAPPLICA t
A one: CITY OF CUPERTINO-BUILDING DIVISION /
• G ° a"asp / APPLICATION / PERMIT 1,6
rcbilect/Engineer• BLDINCFLBCTRICALPLUMBING-MEHA
CNICAL CATEGORY CONTROLS
Lic Na: UI
QTYEL &TRIC PE IT FEE BUILDING PERMIT INFO
Address: PERMITISSUA 200 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc AP?UANC1*RES&TTAL`jy 108 DESCRIPTION
Ingwith Sedion7000)of Dlvlslon3ofthe BudnessanriproI IoneCede,and my
Ilcenss is in B are tett. �il(J PANELS,
Llcen C.
k.& b7 e� ,�L�C
Date Contract z
ARCHITECES CLARATION 11000
pZ [un stand my plam.hall be used as public record& O PS SQ.FT.FLOOR AREA S/SQ.FT.
0O
y E Licensed Professional
I-e�FEi'h OWNER-BUILDER DECLARATION a LCIRCNT/ 1 -
ZI-'iA Iherebyaf ,mthatlamexemptfmmthe ContradoesLlansehwforthe
following reason.(Section 7031.5,Business and Professions Cade:Any city or
O 7TMP.ME77R0 LEI T.
El,, county which requprior inapeuNtto alsore uires th, applicant
for
such permit
o
any structure pater e t that
he Is also sed pursuant the tensionof e POWER DEVICES
file a signed statement that M b licensed pursuant to the provisions of the
3n, Contractor's License Law(Chapter9(commencing with Section 7000)or Divi- SWIMMING POOL ECRfC
0:! slon3ofthe thskeavane ProfenlmuCode)orthat hebeaemplthererromand VALUATION
O the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSW[TCIiESHXTURFS
applicant fora permit subjects no sthe applicant to a civil penalty of nmorethan
five hundred dollars(5500). NEWRERDENTIALELECTRSQ.FT. STOWLS TYPE CONSTRUCTION'
�n ❑I,as her of the property,or my employees with wages as their sok
compensation,wllldothe work and thestruature b not Intended or offered(or bad
qvie(Sec.7014,Bwlnnn and I'rdeniov Cade:The Contractors License Law
does not apply to an owner of property who build&or Improves thereon,and OCC.GROUP RFS.UNITS
wl od...chworkhtmeselforthrough hlsawn employees,provided thatsuch
improvements am not Intended or offered for sale.If,however,the building or TOTAL: &
Improvement issold within one yea rofcompletion,the owner-bullderwlll have
I"rden of proving that he did rut bund or Improve for purpose or sake). QTY, PLUMBING PERMIT FEE
L.I L as owner of the prepeny,am exclusively contracting with licensed FOOD ZONE AP"
PERMIT ISSUANCE
rontredws to coretrod the pmject(Sec.70/4,Businessand Peofessiaa Code:
no Contracture License Law does not apply to an owner of property who ALTER-DRAIN&L VEM-WATER(EAI
bunds or Improves thereon,and who contacts fee such Inypects with a FEE SUMMARY
�gR�factor(s)licensed Pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE ILC
LJ I am exempt under Sec. B 6 P C for this reasonQITTQnnr
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• WORKMAN COMPENSATION DECLARATION ftTGFR'TR
❑I hereby affirm that I have a certificate of consent to self-Insure,or FD(TURPS PER TRAP SCIfOOL TAX Y N
certlfiateof Wor Fompe.ti.nl...a Qoramdifiedmpythereaf(Sec. RECEIPT
Policy /DIT _ (� CAS P.A.SYSTEM-1 WC.4OUTLETS PARK FEE Y N
PoOry a `��f�ll JJ RECEIPT N
GAS. SYSTEM-OVER 4(EA)
Co nv a aT 1 A. BUILDING DIVISION FEES`"iB�"�'y �'�' okfr� CREASE/INDUSIRLWASfEINTERCII'TOR PLANCHECKFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM CA 20081. Date Recd t#
Ghls,metlon need not be completed lithe permit k forms hundred dollars P
(E700)oilev.) WATER HEAT ER W/VENT./ELCCTR ENERGY FEE Y N—
I
net that emin ploy
an pens .in an lone,work so
s tobe.s pert bjmit is issued,
I shall not employ any pawn In any manner w u to become subft to the WATER SYSTEM/TREATING
Workcra'Compenvllon laws of California.Date PAID
O Z Appliant NEW RESIDENTIAL PLMB. POET. Date Revel tN
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
Hshould become subject to the Workem'Comperwtlon provisions of the Labor - TOTAL:
N Code,you moat forthwith comply with such provisions arthis permit Mall be BU
ILDING FEE
IL > deemed revoked.
d C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyafBrm tMW
hat there is a commehon lending agency teethe perform ELECTRIC FEE
M Z and afthe workforwhichthis pert is ued(Sec.3097,CIv.C.) TOTAL:
O O lenders Name PLUMBING FEE
U. le.der.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certllythatl have read thtsapplicationana slatelhatthe above lnfomalian
C iscerrect.I agreeto comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
>. W relating tobullding construction,and hereby authorize representativn ofthis
F city to enter upon the above,mentloncd property for Inspection purpose.. ALTERORADD'TOMI:CH,
V (We)ag ec sae,InaemNty ane n.mdev me cl ora But Date Reccipifl
ago etllablBti,' gments,rostaa sea whicheneyi nywa ecrue AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL:
&gal told Ci 1 con en.fl gr tingof cele
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SlknifidW.TA Bart/Con actor W EXFTAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD US MATERIALS DISCLO RE -
Wllltheappllanlor(umre ullding occupant store or andleh ardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei tic
I lealth
Yea
Safety Cod%§te Jloon 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑
WIIltheappllantoaown,building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which runt hazardous air contaminants as defined by the Bay Area Air
•
Quality Management Q�Wct7 BOILER-COMP(31-11?OR 100,CM BTU) AID
4 Yes No PAID
havereadl alth& nue mode, erequireasrtaunderChapter 6.9>o( BOR.ER-COMP(OVIR 100,001)BTU)
the Calllornia Elcalth k Safely Code,Sections 75505,75537 and 75536.I OCT pp [3 (�
u rstandthat if the building ones norcurrently have.tenant,that itismy NEW RESIDENTIALMECH. OC G V SQTr 1990
repo ibilily to Ally theoceupanto the 9qtrement,whip most mot
P ort Ensnare aCertifi of 0 pa '
c G �1�!a.►rIII,b,
Owneror.utho � agent Date TOTAL: IASUEDBY:
OFFICE COPY