21975 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 21975
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wnsr.N,7A ze
4 an: CITY OF CU PERTINO-BU ILDING DIVISION '
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C tvctor'•Name t Lie.Na APPLICATION I PERMIT 3—
. :PIBUILDINGELECTRICALPLUMBING-MFOHANICAL CATEGORY CONTROL
hit
Arcect/Eagreer Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE .� El
❑
LICENSED CONTRACTOR'S DECLARATION I/`7
I herebySectiolrmthatl ivsionsedheunder ofChapter APPLIANCESRESIDENTUL JOB DESCRIPTION
lnense I.Mlailfar eainflicon3o(theBusirre.adProfeesionsCade,andm
II«n.le In fail lora and E( PANELS
Llan.Clot LIC X71 110
Date -AArjContractor
ARCHITECTS DECLARATION 201-IODOAMPS
0 2: I under stand my plans shad be used u public records. OVER 10DO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
LI«need Profeallmal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFOLLLCEtCU1T/MLSC
Z Ihereby affimnthal l am exempt from the Contractors Llan.Lw for the
OO following reason.(Section 7011 S,Business and Profession,Code:Any city or
�ZI"'"' county which requires a permit to coramict,atter,impmw,demolish,or repair TQ'1P'MEIFR ORPOLE INST.
q�
anyatructureprimt.ite leauance,alw requlra theapplfmtfwmchpermitto POWER DEVICES
P-1 O3 file a signed statement that he is licensed pursuant to the provisions of the -k— ?
W6 u0, Contractor's License Law(Clupter 9(commencing with Section 7000)or Divi. SWIMMING IDOL ELECTRIC VALUATION
sion3 ofthe Business and Prore.lmis Cade)mthat he is exempt ta
herromand
the basis for the alleged exemption. Any violation of Section 70115 by any OVILEISSNTTCHIESFLXTURES
appBant fora permit subjects the applicant to a civil penalty of not more than '
fWundred dollars(SM. NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
I,a owner of the property,or my employees with wages u their sole
compensation,will do the work and the•truetum is na intended or offered for -
O ale(Sec.70A Business and Prormbns Code:The Contractors License Law
r3$ does not apply to an owner of property who bullds or improves therein,and OCC.GRDUI' RES.UNITS
who does•uch work himself orthrwgh Ms own employers,provided that such
Improvements are nes intended or offered for aide.r'4 however,the building or TOTAL:
Improvement is sold within omyearcdcompletion,the owner-build erwill have '
thLpdrden ofprovingthat he did nes build or Improve for purpose of ule0. QY]', PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner or the property,am exclusively contracting with umnsed
contncrom to construct the project(Sm FIRM ISSUANCE
p pct( 014ly to are.and of prop rt Code:
The Coor imp's Llan. on, does nes apply tom owner of property who /yam-DRAIN&VENT-WATER(Fit.
builds t r Improve thereon, and who contracts for such plopm with a FEE SUMMARY
cgBlfaamexe vednder Setto the Conlntlors License Law. BACK FLOW PROTECT.DEVICE
lJ I am exempt under Sect B k P C for this reason
OUTS I DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEII'1'=
WORKMAN COMPENSATION DECLARATION 1'1 SCHOOL TAX ' Y N
❑I hereby orke that I have o lmura to or consent to opysalFirgum,hemof or a 1 FIXTURFS PER lr ��c C� RECEIPT I
certiflateofWorknn'Compensatlanluurana oraartifkd mpythereo((Sec. GAS EA.SYSEM-]INCAOUTLLTS PARK FEE Y N
3800,Lab CJ RECEIPT 8
Po11ryY I�o1s GAS EA.SYSTEM-OVER4( A)P
Cam BUILDING DIVISION FEES
Certified copy is heed with the
city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V(fled with the city inspection division.
CERTIFICATE OF UMPT10N FROM WORKERS' GREASE IRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FC Date Reeei t#
Rhls.ctlon need nes be completed BIM permit V(orone huntlred dollars
wMarlee,') WATER HEATER w/v&vr/ELECTR ENERGY FEE Y N
I mmfy that In the performance of thework forwNch this permit is issued,
I shall nes employ any person In any manner s,a to became subject to the WATER SYSTEM/TREATING
Workers Compensation lawsof Callfomla.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Daft Recei til
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become sub}mt to the workers'Compenatmn provisium ofine Labor TOTAL:
jr N Code,you moat forthwith mmply with such provisions orthb permit shall be
LU 9 deemed revoked.
d C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is.coutadion lending agency for the perform ELECTRIC FEE
n Z an«ofthe workfor which this permit is issued(Sec.3097,Civ.C.) TOTAL:
0 O Lander'a Name PLUMBING FEE
LL L— Lender•Addre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Otythat I have read ted•appllmtionand slatethat theabove Information
6 bcormct.I agree to comply with all cilyand eoamyordinances and mate laws PERMIT ISSUANCE FEES PAID:
relating to building comiractlan,and hereby authodae representatives of this
F N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recel t#
V aS.hut liabilities,)adgment.,cost endexpeueswhkhmayinanywayaame AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalnstcal in an•erye,y,`Jo(the granting of thl•pe i. AIR HANDLING UNIT(OVER I BM CFM) CONSTRUCTION TAX
sista nes Applicant/Contractor 3� EXHAUST xr3oo(w/Duch CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding occupant store or handle haurdous HEATING UNIT(ID IOO,ODO BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCade Section 25532 WI HEATING UNIT(OVER 100,000 BTU) TOTAL:
M Yea f]No
Wlllthe applicant or future building occupant useequlpmnnt ordevims VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air
'� Quality Management District? - BOILER-COMP QHPOR 100,(1N BTU) PAID
Yes ❑No
haveread the haaardo.material.requirements under Chapterb.95 of HOMER-COMP(OVER 100,000 BTU) �v'�n Ina
.the Callfomla Health&Sar' Code,Sections 25505,25533 and 25534.1 A R
understand that lfthe building does not amently have a tenant,that it is my NT:TVRESIDENTIALMECH. SQ.FT
responsibility to notify the occupant of the requirementiwhich must W met
prior to Issuance of a Certificate of Occupancy. pl rsi Puf1p 'A(I
Owner or authorind agent Data ISSUEDBY YLk Vh M_ C"
TOTAL:
OFFICE COPY