21055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Add ress: 21055
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ners one:
CITY OF CUPERT[N0.DUILDING DIVISION
Col= Lk.No: APPLICATION I PERMIT ( Z
bi B(JfLOING-ELECTMCALMU BINGM HAMCAL CATEGORY CONTROLp
Archluct/Enginesr. Lt..No:
CITY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: .PERMITISSUANCE ❑ ❑ ❑
LICENSED COensed under
DECLARATION
I herebyafflrmtWt laiAlan3oftheerprovlsldPmfhmor9dc andn APPL[ANCFSRES[DENIUL JOB DESCRIPTION
It..i infon70W)ofdeffeon3o(the BuNnessand ProfeulonsCode,end my ^'
limnse Is in s d effect. PANELS - (`" `/ V
Date
r due- actor 81 S'
Dale GOIItO[tnlAXmQ
ARCHITECTS DECLARATION 701- "AMPS
9z I understand my plans shall be used as public remade. OVER TWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
o O
Fi Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLA
zL, IherebyafOrmthat l am exempt from the Contractor's License Law for the
QQ qq following reason.(Section 7011.5,Business and Professions Code:Any city or
C" ty county which requires a permit to construct,alter,Improve,demolish,or repair TEMP.MEIER ORPOLE INST.
`a 7 any structure prior to its lsmance,also requires the applicant for such permit to POWER DEVICES'
r file a signed atonement that he Is Licensed pursuant to the provisions of the
SOSContractor.License Law(Chapter9(commencing with Section 70M)of Divi-
tloe3 ofthe Buslnees and ProfessloreCode)orthat hels exempttherefromanVALUATIONd SWQdMING FOOL ELECTRIC
o the basis for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCFB'SFI%TI1R6
applicant fora permit subjectsthe applicant to a civil penalty of not more than
five hundred dollan($500). NEW RESIDENTIAL ELECTR SQ.FT. S70WE5 TYPE CONSTRUCTION`9..' I,as owner of the property,or my employees with wages as their sole
aconspensatlon,wllldothewmkandthestmu to Isnot Intended or offered for U - (3}
O elle&.7014 Busbies,and Pmfeadme;Code:The Connectors License law
$ does not apply to an owner of property who builds or improves thereerh and OCC.GROUP RFS.UNITS
whodoessuchwork hlmseBmthrough Msownemployee•,provided thatsuch
Improvements are net intended oroffered for sale.It however,thebullding or TOTAL:
Improvement 6soldwithirmayearofcompietloo,theoweer-builderwlll have
tht*rden of proving that he did out build or Improve for purpose ofeale.). QTY, NPLUMB?&_GPEVtMIT FEE
LJ 1,as owner of the property,am exclusively mntraml^g with licensed FLOOD TONE APN
contnctorsto constrottthe project(Sec.7My BualnemaM Professions Code: T UAN
The Contractor's License Lw does not apply to an owner of property who
Wilda or Improves thereon, and who cordrscts for such ptojects with a A IN - TER(EQ
ctor(s)1lcensed pursuant to the Contractor's License Law.II am eFEE SUMMARY
Ll exempt under Sec. B k P C for this reason BA PR .DOICE
OUTSIDE FEES
SANITARY Y N
r Owner Date D i A FID. RECEIPT
WORKMANCOMPENSATIONDECLARATION Tie SCHOOL TAX Y N
01 hereby affirm that I have•certificate of consent to aelf-lnaure,ora g_ NECEEPT M
'(b certificate ofWorken Compensationlnsurancema certified mpythereof(Sec. �, s I13LEf5 PARK PFR Y N
3800,lab C.) RECEIPTNp
Pa1kyY
Com any ��' ERd(EA) BUILDING DIVISION FEES
Certified copy is hereby furnished. CREASE/W LWASTE INTERCEFTOR PLANCHL•CK FEE
❑Certified copy Is(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE - PAID
COMPENSATION INSURANCE SEWER. ARY-STORM FA XIOpI. Date Recei t#
(this lonneed notbecompleted lithe permit Isforoashundreddollars
(SI 00)or less. WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance ofthe work for which this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Wmrkers'Compenaation Lawof California.Date PAID
C' ZApplicant NEW RESIDENTIAL PLMB._SARI'. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'ComperuatIn.provisions of the Labor IOTA
N Code,you must forthwith comply with such probilons or this permit shall be1N.
W y deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyaffirmthat there Is a construction lending agency forthe perform TOTAL: ELECTRIC FEE Q
Z an.of the workfor which this permit Is Issued(Sec.3097,Cie.C.)
U O Lender:Name PLUMDINC FEE N
F tender'.Add. QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW bract. tagreet compteread hbapplkatynanddcoo yordtances;edgat laws
1 Ismrmct.]agreetocomplywithall cityandcountyoedinanceaendpatelaws PF1tMTIISSUANCE FEES PAID."
relating tobullding construction,and hereby authodn representatives ofthb
H Z city to enter upon the above-mentloned property for Inspection purposes. ALTER OR ADD 7LY MECH. Date ReCe t#
(We)agree to save,ledemnify an d keep harmless the City of Cu pertlno
V against WbNtiesjudgmens,coats and expenses which may in any myammo AIR fiANDLING UNIT(f010,000 CFM) SUBTO L:'
against aldcityfn n nce of the granting of this permit CONSTRUCTION TA
a AIR HANDLING UNIT(OVER IO,OW CFM) ,
Ignature of Applicant/Contractor to CICEXFLIUST HOOD(W/DUCT) CONSTRUCTION TA PAID
:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or hand Is hazardous HEATING UNIT(TO 100,000 BE U) Date Rece t#
=tonsI as defined by the Cupertino Municipal Code,Chapter 9.17,and the
lies lth and Safety Cod .§podon 25537(a)7 HEATING UNIT(OVER 100,000 BM
TOTA
❑ , L ISSUANCE DATE rebuildngoapantumequipmntodevices VENTILATION FAN t51NCLE RESIU) f.Y
which emit hazardous air motamlns eta as defined by the Bay Area Air
Quality Management DlsWct7 BOILER-COMP(3FB'OR 100,OfD 0"Cl))
Yes I o
ave read the haze esus materials requirements under Chapter 6.95 of BOILER-COMP(OVpi]00,000BTU)
the California Health k Safety Code,Sect lora 75505,25533 and 75534.1
understand that if the building does not currently have.teoanL that It Is my NEW RESIDENTIAL MECH. SQFr l� `�n�
responsibility to notify the occupant
of the requirements which=at be net _ ` 11..11
prl�isauance Mace ry(IA c,tes
O herorrraasu/IetaAh'°mire/dd agent
Date TOTAL ISSUED BYY(1�0.
OFFICE COPY