21641 AFF_LK;ANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
w 9u0RatgeAdd Buildingproject Identification PERMIT NO.
2 603 c�s•r��,ro� s crz e�—r 21641
mer. dine„ F}IJ OL �
I7 �e� CITY OF CUPERTINO-BUILDING DIVISION
Comrades.Name: Lte.Ne; APPLICATION /PERMIT ' _ 7 -GJ
Architect/Englnmr. Lie.N. BUILDING ELECTRICAlePLUMBINGTFMECHANICAL CA DRY CONTROL N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE 1:1 1:1 1:1 -
LICENSED CONTRAROR'S DECLARATION
Hurebyafflrenthatlamlkensedunderprovision..f Chapter9(rommmo APPLIANCES-RESIDENTIAL JOB DISC
Ingwlth Sedion7000)of DIV W on3ofthe Buslnewud Professlonsfode,and my
Berne b le fuU force and effect PANELSLI D'e�
Date less Lk.N
Date Gr X111000 AMPS
•
ARCHITECTShallbeused
DECLARATION
p OCC` lundentand my plata dull be used espublic records. OVER1000 AMIa5 SQ.Ff.FLOOR AREA E/�.FT.
od0 Licensed Professional I ' SIGNSELECTRICAL
<«<� OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MISC
Z � I Lerch y afOrm that I sin e.emptfrom the Contractor's License law for the
Wfollowing reason.(Section 7011.5,Business and Profusions Code:Any city or
OZ TEMP.ME[EROR POLEIN7sft
F� county which requires a permit to construct alter,Improve,demolish,or repair -
$$$ anyrtructure prior to lb Issuance,Worcqulrtathe appUrant(m such permit to ppyypR DEVICES .
5 (Ile a signed statement that he Is Ucenud Pursuant to 1M provIsions of Ne
ry
Contractor's License IA.(Chapter 9(wmnstncing with Section 7000)o(Divi. gWAAfiNG POOL ELECTRIC VALUATION O O
ston3o(the Buslnesesnd Pro(essbns Code)orthst hebexemptthere(romand
y.'••....7777 the basis for the alleged exemption. Any violation of Section 7031S by any
Q OUTLETSSWITCHESF[XTUBES (/
applicant fora permit subjects the applicant to a civil penalty of net more than
five red dollar($SM.
as owner of m NEW RESIDFN7iAI,ELECTRSQFE. SR7 TYPE CONSTRUCTION
�n p perty,or my employer with wage u then sob
compensation,will do the work,and the structure is not Intended or offered for
OIn CS..7044,Business and Professions Code:The Contractors Limns law
$ does net apply to an owner of property who Wilds or Improves theme,and OCC.GROUP RFS.UNITS
who doe such work himself or through hisown employee,provided that such
Improvementsare nm intended orof(ered formic.If,however,thebullding or TOTAL.
improvementbwldwithinomyeamfmmpbttogtheowner- fiderwillhave
thrii*rden of pmWng that he did next Wild or Improve for purpose o/uled. QTY. PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with Beenxd FLOOD ZONE APN
centmetem to construct the project(Sm 7044,Business and Professions Code: PERMITISSUANCE
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN k VENT.WATER(RAI
or imp.thereon, and who contracts for such projects with a
ogntractor(s)Licensed pupQpyyyani to the Cmtoid e.Llmnse Law. FEE SUMMARY
Ul am glempt uM /l B k P C for this reawn BACK FLOW PROTECT.DEVICE OUTS1 DF E
Owner 1 11 �T :;P
I Date I� DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
(WORKMAN COMPENSATION DECLARA 10 RICEI1711
pl hereby affl.that I have a cerificate of consent to self-insure,ora TURES PFR TRAP SCHOOL TAX Y_ N_
mdlflouen'
certificate Insurance artl(Ied copy thereof(Sec. ftECE PT Y'
Lab CJ GAS EA.SYSIFM-1 INCA OUTLETS PARKFEE Y N
Policy
olicy Y GAS FA.SYSITM-OVER 4(EA) . DING DI M
Cam any BUILDING DIVISION FEES
�C.diredwpy Wffl led thil ed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Cedified copy is Ned with the city InspMion division. 2�r
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID O
COMPENSATION eediftINSURANCE SEWER.SANITARY-STORM EA.XIOFC. Date Recei t#
(This section need mat be completed if the permit b(orom hundred dollars
($1E0)ualeaa') WATER HEATER W/VENT/EL[CTR ENERGY FEE Y .N
I mrtlfy that In the perfomunce of the work fmwMrh this permit Is Issued,
I shall not employ any peraon In any manner w as to become subject to the WATER SYSTEM/TREATING
Workers'CorepenwBon Lawsof Califomit. Date PAID
-
Z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recel f#
Z O NOTICE TO APPLICANT.If,cher ma king this Certificate of Exemption,you
should became subject to the Workan Compensation provisions of the Labor TOTAL'
N
Code,you=at forthwith comply with such provisions arthb permit shall be
LUQ decreed revoked. BUILDING FEE
aELECTRIC FEEL
TOTAL:CONSTRUCTION LENDING AGENCY SEISMIC FEE
[hereby a!@m that there Is a construction Lending agency for the perform
an.Z arm efthe work for which this permit bbec,sued(S 3097,Civ.C.) '
o2 Lender:Name PLUMBING FEE
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W bmIcertifythat l haveread this appUom
tionand statethat theaboveinfovtion
(j rrect.I agree to comply with all city and countyordinanen and state laws PERMIT ISSUANCE FEES PAID:.
>- 0' to building mutmae re
ction,and hereby suthoripresenbtives ofthis
2 •s city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMFCH. Date ReCei t#
(We)agree to ave,Indemnlfy an d keep harn0ess the City of Cu pedlno
agaWt @I judg ,mstsand eapenen chmvylnsnywayaccmre AIR HANDLING UNIT(TO 10,ODDCFM) SUBTOTAL:
aga= C i =and the ant o(thb perms 1
�/'7/� f AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Sigmtu of Applimet/Contractor .Dab EXHAUSPHOOD(W/DIIC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei !#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Scc lon 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
MYes M No
Will the applicant or tum builciingoccupant useequipreent ordevima VFMLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hares Mena air contaminants as dented by the Bay Area Air ��
duty Management D❑lerict2 - BOILER-COMP OHP OR 100,000 BTU)
Y Y" N No
have read the haze omaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BILI) e�R{' s,a �n�1
the California Health k SafetyCode,Sections 25505,25533 and 25534.1 ( e7 l
understand that lithe building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQFT
responsibility to notify the occupant of the requirements which rust be met
prior to Issuance of a Certificate of Occu Fancy. A�0.ot
Owner or authorlud agent Date ISSUED
TOTAL: BY: MVV 1r`LJ
OFFICE COPY
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