21682 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Prom ldentlflotlon PERMIT NO.
BuOding Addrtas:_ 21682 ..
lJw
N e.
CITY OF CUPERTINO-BUILDING DIVISION
cone AA e.Nm: APPLICATION /PERMIT L
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CON79LM
`AmhItect/Engineer. Lk.No:
Qiv ELECTRIC PERMPI'° `' FEEBUILDING PERMIT INFO
Add. PERMITISSUANCE 1:1 ❑ [DLICENSED CONTRACTOR'S DECLARATION
Ihereby efflrmthat l am licensed under providons o(Chapter9(commene- APPLIANCES-RESIDENTIAL JOB DCSC ON
ingwlth Sedton70W)Ot Dlvisicn3ofthe Buslneuand Prot c1 ns e,and my
liwveie lnM ( dfed PANES 7— F
Lice LLCM SY'/�,r��'
to Contract r
UP TO 2DO AMPS
ARCHITECPS DECLARATION 201-I0W AMPS
9CO I understand my plane shall be used as public records OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
E U(0 Licensed Professional SIGNSELECTRICAL
t 6 OWNER-BUILDER DECLARATION SPECIAL CR4C[RT/M1SC
F„ y Ihereby affirm that l am exempt from the Contractors License Law for the
Z 'q❑n following reason.(9ectlon 7031.5,Budneea and Profeslom Code:Any city or METCR ORPOLE INST.
TEMP.countywhkhrequiresapermlttommtmd,aller,impmve,demollshormpalr
anye"mmpdortotto smancgal mquirestheappllcentfarsuchpermltto TEMP. DEVICES
rEd 0.S file a signed statement that he b licensed puouant to the provisions of the
O a Contractor's License Taw(Chapter9(cxmmrencing with Section 7000)of Dlvl-
�OS don3ofthe Buninesand Profeslorecode)orthat hebexempHherefromand SWIMMNGPOOLELECTRKVALUATION
< the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEISSWITCFTESH
O
applicant fora permit subjects the applicant to a civil penalty d net mare than
$ five hundred dollars($500). NEWRMDDMAI TR .FT. 5TOIU6
M I,as owner of the property,or my employees with wages as their sok TYPE CONSTRUCTION
compensation,will do the work and the stmeture is net Intended or offered for
,.? O sole&c.70K Business and Profendom Code:The Contractors License law
does net apply to an owner of property who builds or improves therm,and RFS.
0.0. who does such work himself orthrwgh his own employees,provided that such OCC.GROUP UNITS
improvements are not intended oroffered for sale.If,however,the Wilding or T TML:
Improvement bsold wlthinoneye.,.fcampldlon,theowner-bugderw01 have
tl�uden of proving that he did not build or Improve for purpose ofukJ, QTY•l".' I,UMiI G T FEE . F(ppD TONE I Mal APN
Lf 1,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 706/,Business and Profesios Cade: PERMIT ANCE
The Contractor's License Law does nor apply to an owner of property who �,�-D &
builds or Improves thereon,and who contracts for such p(ojeds with a - }
,,yIBB(ractor(s)licensed pursuant to the Contractor's License Law, - „FEE SUMMARY
=Lj 1 am exem)rt under Sec B&P C for fhb reason BACK W ECT.D
Owner Date
DRAINS. ROSANITARY Y_ N
- Op,A
❑ ORIGIAN COMPENSATION DECLARATRECEIPT 0
ION b FIXIVRES I'ER TRAP SCHOOL TAX Y N_
00 I hest (firm that I have a corti0cete of consent to self-Inwre ora RECFFB NN
corti(Iwte ofWorlocs Comperuatlonlrsurance or a certified copy thereof(See. GAS EA.SYSTEM-11NC.60UTLETS PARK FEE Y N
3800,Iab CJ _
Policy Y RECEIPT M
Com an GAS EA.SYSTEM-OVER4(EA)
Y BUILDING DIVISION FEES
Certified copy S hereby filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
j�Cnrtltled copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200frr. Date Recef ted
Ghb section need not be completed lithe permit b(Drone hundred dollam
(S1 W)ofyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
(certify that In any person
any a wokso as to b corn emNj Mused, —
I shall net empty any person In any manner m es to become subject to the
kre
e 'Compenuws Compensation laof California. ATER SYSTEM/TREATING
(ornla. Date pA]p .
O Applicant - Date Re i tN
Z O NOTICE TO APPLICANT.If,after making this Certlflceteof Exemption,you NEW RESIDENTIAL ELMS. SQFT,
1" should become subject to the Worken'Compesation provisions ofthe Labor TOTAL:
U) Code,you resat forthwith comply with such provlslurs arthb permit shall be
_ j deemed revoked. BUILDING
aI hereby affirm that there is a construction lending agency for the perform
a
G CONSTRUCTION LENDING AGENCY SEISMIC FEE E
LECTRIC FEE
...of the work forwhlch thin permit Is issued(Sec.3097,Civ,C.) -• TOTAL:
(� O 1<naer.Name
LL F Lenders Addreu QTY. MECHANICAL PERMIT FEE FEE - -'
O W Icortifyth.tlhavereadthbappliotionandrtatethattheabavelnfarmatlon be.mect.Iagmetcomplywlthaldtyand countyordlnances and date laws PERMITISSUANCEfl relating to building construction,and herebyauthmiaercpre,cm.tivesofthiscity to enter upon the above-mentioned property for Inspection purposes. ALTIRORADDTOMECH.(We)agree to save,Indemnify an d keep harmless the City of Cupertino Receiptft
against) billties,' gmenb,codnand e.pvme. ich may In my way amus AIR HANDUNG UNIT frO 10,000(FM) UBTOTAL•
agami ciClty cxxaquem the granting Ms peAIR HANDLING UNIT(OVFR IB,B90 cFM) - N TAX
Slgmturc of Applicant/Cont ctor Date E(HAUS'r HOOD(W/DU(tT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS 6CLOSURE
Will the applicant or future building occupant store or handle ha>ardom HEATING UNIT(TO 100,000 BTU) Date Rec i ted
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
HeaRh and Safety Code Section 25532(.)? HEATING UNIT(OVER 1 Wp00 BTU) TOTAL:
I]Yes M No
Willthe applicant or fubme building ompant useequipment ordeviccs VENTILATION FAN(SINGLE RESID) r �g$py��E DATE
which colt hazardous air contaminants as defined by the Bay Area Air �J'w
Qua lity Management District? - BOILER-COMP QHP OR 100,000 BTU)
4 Yea 9 No pp 799,
have read the bas o..materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)) �pN, 1 V T
the Callfomla Health&Safety Code,Sedlos 25505,25533 and 25534. I �e
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
reeporsibll ltyto notify the occupant of the mqulrcmentswhich must be met
prior to Issuance Df a Certificate of Occupancy.
Owner or authorlud agent Date ISBUED BY:
IOTA L: —
OFFICE COPY