21330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ea Identification PERMIT NO.
Building Add a: 21330
wzz ears are/s: one: A
,v LAw — 9 _& � 1 CITY OF CUPERTINO-BUILDING DIVISION L —Z.-Lk--q0
Contractor's Name: Lk.No: APPLICATION / PERMIT
r—�6 15 O BUILDING-ELECTMCA6PLUMBINGMBCHANICAL CATEGORY CONTROL Y
Architect/Engineer. Lit.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFRMITISSUANCE - 1:1 1:1 El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(rommec APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
iegwlth Section7000)ot Dlvlslon3ofthe Businee and ProfesionsCodgandm
nseotln fu f-yg_ Contra
OU �� PANELS /� y" ` �
Z.Clea 10 Pk"i?,`Y
ate Contractor_{, W
ARCHITECT'S DECLARATION 201-1000 AMPS
9 ZO I understand my plans shat be used as public records. OVERT PS SQ.FT.FLOOR AREA $/SQ.FT.
E d�j Licensed Professional SIGNS E CALnY
�Q OWNER-BUILDER DECLARATION SPECIALC aT P
t^ G Iherebyaffirm that I am exempt finenthe Contractor's License Law for th �-
pqqqq following reaan.(Section 70315,Business and Professions Code:Any city o <rryy �
rcounty which requires a permit leconamod,alter,improve,demolish,arrepar 7AiP.ME1TROR POLE IN f.
q' anystm=mpriortoiw Wuama alwrequbealheappl¢etforsuchperMt s
ryE Ale a signed statement that he Is licensed pursuant to the provisions of th AWERDEYICES
w Contractors Llceve Law(Chapter 9(contract g with Section 7000)of IS SIVIMMIN POOL Cf%C;t
�O sion3ofthe Businessand ProfessiomCode)orthalheiaae
emptf�' rad -VALUATION
the basis for the alleged exemption. Any Violation of Section 7 any t' t
OAapplicant fare permit subjects the applicant to a civil penaltydnd ears than O11 1
five hundred dollars($S00). EI TR SQ}T• STORIES - TYPE CONSIRIICTION
I,as owner of the property,or my employees with wages as Ihelr Bole
t mmpensallon,wllldothe work and thestrucwrcbnot Intended or offered for
5 O sale(See 7044,Business and Profealmu Code:The Contracto/a Licerue law _
p RF does net apply to an owner d property who builds or improves thereon,and OCC.GROUP RES UNITSEE:: who docamuch work him elf¢ w
LV
thegh Ms own employees,provided that such
Improvements are nor Intended araffered forssle.If,however,thebuilding or TOTAL:
improvement Eased withinoneyearofcampleliogtheowner-budderwlli have
thakurden of proving that he did read Budd or Improve for purpose of sale.). QTY-1 PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(See.7004,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does n¢apply to an owner of property who ALTER-DRAIN As VENT-WATER(EA)
Wild.or Improve thereon, and who contracts for such p -
1pones with a FEE SUMMARY
ou curds)Liters Pursuant to the Contraatm'a Llanse Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec rea
B A P C for this son
OUTSIDE FEES
GRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
• Owner Date -
RECEIPT Y
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm That 1 have a certificate of consent to self-Inmre,¢a RECEIPT N
cxmfloteofWorken'Compensation Luureace me certified ropy thenvf(Sec. GAS EA.SYSTEM-I INC4OTTLETS PARK FEE Y N
3800,lab C.) RECEIPTNN
Policy GAS FA.SYSTEM-OVER 4(FAT
BUILDING DIVISION FEE
9RZrayS
l d copy I hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA.200FT. Dale Receipt#
(This section need nor he completed If the percent dfar ane hundred dollar
($1 00)difytor WATER HEATER W/VENT/ELFICTR ENERGYFEE Y N
1¢rtify that Nlhe performance of theworktorwhlch this pertnit is iaeaed, _
I shelf net employ any person In any manner an as to became subject to the WATER SYSTEM/TREATING
worker:Compensation Laws of California. Dale PAID
Z Z Applicant - New RESIDENTIAL PIMB._SQ.Ff. Date Recei t#
'Z O NOTICE TO APPLICANT.If,after making this CeetBlcateof Exemption,you
should become subject to the Worker 'Comperuallon provotiom ofthe Labor TOTAL:
CCN Code,you muat forthwith comply with such provisions or this perm shall be BUILDING FEE
W `J deemed revoked.
CONSTRUCTION is HON LENDING AGENCY SEISMIC FEE
CL G Thereby ffiromorkfo wthercotacoeuucilon ler Wing a 7,Civ.C.) perform ELECTRIC FEE
L) 0 Leader'the work for which shot perrtatb Weed(See.3097,CIv,CJ TOTAL:
Lender's Name PLUMBINGFEE
LL H Lenses Addeea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedlfythall have
oesms ly.1ththis pBcitlonand dco.etethat y.ediheabovedstateason
CL
otcorred.Ixgrre to complywltha0dtyand muntyoedlnaneea and Yale laws PERMIT ISSUANCE ZxCU FEES PAID:
�. relating tubullding construction,and hereby sell a repmsenlativen of shot
F N city to enter upon the above-menllnrsed property f rupectbo purposes. ALTERORADDTOMECH.
? (We)agree to save,Ind fy and ep ha a the City of Cupertino Date Receipt#
V agaWt ibbillt jadg a •and n hi eneyln cerate AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
agaivl In con race call tt of la permit.
AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
gratum%LArpI ted Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ,.,p
Will the appllcanlorfuture building odupanbsore S=SURE oat t(FATING UMT(T0100,000 BIW eVv Date Recei t#
material as deflaed by the Cupertino Municipal Cede,Chapter 9.12 an c
Health and Safety Cade Ion 25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL: fay
❑Yes No
Will the applicant re building occupant use equipment or devices VENTILATION FAN RINGLE RESID) ISSUANCE DATE
which emit harardous air contaMents as defined by the Bay Area Air A'
. Quality Management DLa 7 BOILER-COMP QHP OR 100,000 BTU) PND
❑Yee o
]have read theh oats materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) q ;]Q
the California Health Safety Cade,Se s 25505,25533 sad 15534.1 -0 C j 2 b 1590
understandthat if t buil'In n a atlyhave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
is
to i the prat the Ircmenls which nwstbe met
o r n of Certl(I to f0 CU ({�
City of Perp
neroraut ori agent ate TOTAL: ISSUEDBY: L
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OFFICE COPY