21587 "APP LICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN
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Building Pru act IdentlflneonI w 'T N215 8 7
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Building Address:
oK� <44i:a6loke
are:
,OOTY OF CUPERTINO-BUILDING DIVISION
O Con ctor Name Lie.N. APPLICATION /PERMIT
S 9 BUILDING-ELMMCALPLUMBING-MMECHANICAL CATEGORY' CONTROL#
11.0 Architect/En men Lk.Na
QTY' ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE - ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(comment— APPLIANCES-RESIDENTIAL. JOB DI M-11ON
ingwithSection7000)ofDivislon3oftheBusimmandProfessionsCode,andmy -
IicenaeislnluR o dd(ad. PANQS �RLGDate
Class G� Co # � �s0//.� � 0
Date eV Con �/
ARCHITECTS DECLARATION 201.1 OVER00AM!'S
� pOZ I understand my plansshall be used ss publicrecoNe. OVER 7000 AMPS euQ,FT:FLOOR AREA S/SQ.FI.
E o Licensed Professional SIGNS ELECTRICAL
GG z OWNER-BUILDER DECLARATION
oa SPECIAL CEiCUIT/M19C ,
i.., Thereby zfOrmihatlamexemptfrom the Contractors License Lw(orthe
ZO Z..o following reason.(Section 70715,Business and Professions Code:Any city or TEMP.METER OR POLE INST. ,
F� countywMch requires apermilmorutruct,alter,Improve,donscllsh,orrepair
any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
l file a signed statement that he ls licensed pursuant to the provisions of the
3w Contractors License Law(Chapter 9(commencing with Section 70DO)of Divi- SWIMMING POOL ELECTRIC VALUATION
,ion 3 of the Business and Imfessloru Code)or that he ls exempt therefrom and /
O the bash for the alleged exemption. Any violation of Section 7IX115 by any OUTLETS-SWITCHES-FIXTURES O/e Q�
444WWW555 applicant fora pamut sub)cdathe applicant to a civil penalty of net more than
five hundred dellsn(95M. NEW RESIDENTIAL ELECTS SQ.FT. TYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sok
compensation,will do the work and the structure ls not Intended or offered for
Osale(Sec 7044,Business and Prof....Code:The Contractor.Li..s law
$ docs not apply to an owner of property who builds or improves thereory and OCC.GROUP RFS.UNITS
who does such work lumaelforthrwgh hlsewn employees,provided that such
improvements are not intended or offered for sale.14 howevep the building or TOTAL: i
Improvement is sold within one years(completion,the owner-budderwill have
ttie�urden of paving that he did not build or Improve for purpose of sale.). Qiy, PLUMBING PERMIT FEE FLOOD 7DNE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to..mict the project(Sec.7054,Business and Professions Code:
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves thereon,and who contracts for such plojects with a FEE SUMMARY
�gDf�acov(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I em exempt under Sec. B k P C for this reason - OUTRIIIEFFFS _
DRAINS—MOOR ROOF,AREA,COND. SANITARY V N -
Owner
Data - RECEIPT#
�/' WORKMAN COMPENSATION DECLARATION FDaSCHOOL TAX Y N_
(_a71 hereby affirm that I have a certificate of consent to self-Insure,or a NQS TRAPPRECEPr#
certlfteateol Worlume Comperwtlonlruurance ma certified eopythereof(Sec. GAS EA.SYSTEM-1 INCAOUILEIS PARK FEE Y_ N
3300.Lab C.)
Policy p N4ti64107 y
.J RECEIPT'#
Com any (ate GAS EA.SYSITM-OVER 4(EA) BUILDING DIVISION FEES
Cc
tined copy is hereby fu mashed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Rt!rtified copy Is filed with the city Inspection divklon.
CERTIHCATE OF EXEMPTION FROM WORKERS' GREASE TRAP ,PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT 'Date Recel t# r
(Chic section need not be completed If the permit Is for one hundred dollars ,
($100calem) WATER HEATER W/V7NC/ELECTS - ENERGYFEE Y_ N_
I certify that in the performance of the 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/TREATINGWorkers'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQFT. Date Re I t#
Z NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
,
0 should become subject to the Workers'Compensation provisions of Labor _ TOTAL:
� N
Code,you=at forthwith comply with such provisions orthls permit shall be BUILDING
-
'] deemed revoked.
W CONSTRUCTION LENDING AGENCY - SEISMIC FEE
(L I hereby afRrmthat there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
nd
M Z ance of the work for which this permit N Issued f5ce.3097,Civ.C.) PLUMBING FEE
50 Leer's Name
Iy I— Landers Aadieas QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
U 1cenilythatl have readthisappliczukmand statethattheabove Information
O W iscomact.I agreeb,comply with all city and county ordinances and state Taws PERMITISSUANCE FEES PAID:
> C relating to building construction,and hereby authorize representatives of this
F V2 ' city to enter upon the above-mentloned property for inspection purposes. ALTER OR ADD TO MECH.
Z ,Me)agree to save,Indemnify an It keep harmless the City of Cu pertido Date Receipt#
Viglakst liabilities,Pdgmanta,costa aq x seawhlchmay lnanywayacerue - AIR HANDLING UNIT(TO I0,ODO CFM) SUBTOTAL:
ai teald ity ins �„ n sof th tingofthlsperml^. AIR HANDLING UNIT(OVER I QOOD CFM) CONSTRUCTION TAX
SI rare of Appheant/Contrraactor Data EXHAUST HOOD M/DUCT) 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 t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety CodeLSecljo;,2S532(a)1 HEATING UNIT(OVER 108000 BTU) L:
Yes L-J'IVO VENTILATION FAN(SINGLE RFSID) - [$$ A
Will the applicant or future building occupant use equipment or devices
which emit haaardous air contaminants as defined by the Bay Arca Air � �
Quality Management Dish - - BOILER-COMPQFR'OR 100,000 BTU) („[[J � 'I
4 run
Yes o
have read the haza ous materialsrequirements under Chapter 6.95 of BOILER-COMP(OVQ41fp,00)BTU)
the California Health A:Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that itis my NEW RESIDENTIAL MECH. EQ.FT. ,��,SQ,
res ibilitymnotitythe occupant oft qulrementswhich must be man,issua sofa Ce tiff o c
Owner or authorized agent- Date 'ICITAL: ISSUEDBY
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OFFICE COPY