21772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.ect tdemift Bion' PERMIT NO.
Budding Address: /1 ag
ners Name: G SUaMTTrAI G
S7— n9a CITY OF CUPERTINOBUILDINGDIVISION nn11
iContract 's Name: LIc.Not APPLICATION / PERMIT I
' Architect/Englneer: Lic.Na BUILDINGELECIR[CALI'LI]MBING-MECHANICAL CATEGORY CO OLp
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address S 1 PEtMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION �' ' I]
thereby affirtnthatlamlicensedunderprov%ionsof Chapter9(mmmmc. APPLIANCES-RESIDENTIAL ]O DFSC ON
ingwlth ii,fun7000).ld effec n3.(the Buelnessand Professions Code,and my
license Is U(uB farm and effect. PANES V`/
License C%ss LION �'a5NS5 -
Date ContmRor�O—R1.�—
ARCHITECTSDECLARATION —LM TO 2DO AMS
201-1000 AMPS a
1Q±�DO Iunderelandmypiansshallbe used as public records. OVFRIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
E U Licensed Professional - SIGNSELECTRICAL
�6OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
I here% arenthatlamexempt from the Contractor's License Law for the
02-9 9 fO
following moron.(Section 70315,Buginess and Pmfenlona Code:Any cityor
TEMP METER OR POLE INST
p4 countywhich requires a permittecorutmR,alter,improve,demollsh,orrepalr . '
.a anystructure prbrto italssuance,also requlresthe applicantfor such permitto )'OWER DEVICES
file a signed statement that he b ficeased pursuant to the provisions O( the
3ON Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
ston3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any,
appEcantfora permit subjects the applicant to a civil penalty and more than OUTLETSSWITCHESEXTURES
Ove hundred dollars(5500", NEW RESIDENTIAL ELECTR
�n Lee owner of the property,or my employees with wages as their sole FT. STORIES TYKE CONSTRUCTION
compensation willdothe work,andthestmcNre lead Intended or offered for
O sale(Sec.7066,Business and Pro(esslOns Code:The Contrame.License law
'$ doesnotapplytom owner of property who builds or improves thereon,and
who does such work himself or through his own employees,provided that each OCC.GRO(1P RES,UNITS
Improvements are ti
acntended Oroffered for sale.If,however,thebulldingor TOTAL:Imprm,armntisaoldwithln omyearofcompl&iogtbe.wner-b Rderwillhave
that burden of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLODOZANE APN
LJ 4 as courser of the property,am exclusively co
contractors re construct
with licensed � pp�M1T ISSUANCEM�
struct the project(Sec.7044.Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
beliefs or improves thereon, and who connate for such plojects with a
camr(s)licensed pursuant to the Contractors FEE SUMMARY
License Law. (AIX FLAW PROTECT.DEVICE
I am exempt under Sec. B&P C for this reason '
DRAINS FLOOR,ROOF,AREA,COND. SANrrARY Y_ N_
Owner - Date -
WORKMAN COMPENSATION DECLARATION RECETTN
FIXTURES PER TRAP SCHOOL TAX N_
I hereby affirm that I have a certificate of consent to eel(-Insure,w a Y_RECEIPT N
❑Late o(WOrkene'Compersationtrsurance oracertified copythereo((Sec. CAS F.A.SYSTEMI INCA OUTLETS PARK FEE Y N
3800,Lab CJ
Polity p RECEIPT#
Cam any GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
[&Certified copy b herebyth the he . GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�ertBied copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPPAID
COMPENSATION INSURANCE SEWER- STORM-STORM EA 200FT Date ReL'el t#
Q)or deal
need not becompleted It IAe peeNt%!Drone hundred dollare
($100).lifyth the WATER HEATER W/VENT/E,ECTR r�i� ENERGY FEE Y N_
I cent thatinanypfrmainanymnce of wnerst,ork which th%pesrnilbbothe L-lJ —
Whale not employ any person in any manner m u to berome subject t.the WATER SYSTEM/TREATING
Workers'COmpensatlon laws.(Gilfornia.Date ppjj) '
z Z Applicant NEW RESIDENTIAL PLMB. Date Recei t#
Z O . NOTICETO APPLICANT:If,after making this Certificate ofExemption,you c'U�
Hshould become subject to the Workers'Compamation poevisiOta of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthis Permit shall be BUILDINGFC
deemed revoked.IL mCONSTRUCTION LENDING AGENCY x SEISMIC FEE
a Ihereby affirenthat there%a construction lending agency for the perform- ELr
Oance of the work for which this permit b Issued(Sec.3097,Civ.C.) - TOTAL: ECTRIC FEE
O tenders Name PLUMBING FEE
LL 1— Lender's Addreaa QTY. MECHANICAL PERMIT FEE ECHANICAL FEE
O 111 ILedi(ylhatl have readthbapplicalionand statethattheab.ve Information M
4. bcorrect.l egmato comply with all city and county ordinances and state laws I'FddtMTT ISSUANCE FEES PAID:
} relating tobuildingmrutructlon,and hereby authomm representatives O(this
(— Z city to enter upon the above-mentionad property for Inspection purposes. ALTFA )RADDTOMECH.
(We)agree to esve,Indemnify an d keep harmless the City of Cu patina, Date Receipt#
V against liabilities,Judgments,mate and expenses which may In any way acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agabstuld i Citysequence of the grant Ing of this permit. '
AIR,HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
ct
Signature of Appllcant/Contraor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recti t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)2 - HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 Yes I]NO
Will thexpplicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hawrdous air comaminanle aW defined by the Bay Area Air
Quality Management District? BOILER-COMP DH POR 100,000 BTU)
4Yes ❑No
M1 ye read the bazardous materia%requiremen%under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) PAO
the Gllfernla Health&Safety Code,Sections 25505,25S33 and 2534.1
understand that It the building does not mrrenlly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ}T. - C 'S4 ��Q�
r®porsibllity in notify the..pant of the requlrementswhich at be met - r V a'I,
prior to issuance of a Certificate of Occupancy.
a�� u ► .
Owner oraut orlud agent pale f JI `}srA
'tQ
TOTAL: ISSUE
OFFICE COPY