21395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 21395
21891 CdIZ►E MA�E� LA" E
rptr�—(o6 e CITY OF CUPERTINO-BUILDING DIVISION 11�e
centrator's Name: O Lief.No: APPLICATION 1 PERMIT
���� CATEGORY CONTROLN
Architect Engineer Lk No: BUII.DINGELECTRICALPLIIMBINGMECFIAMCAL
O
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S
CONTRARODECLARATION
I herebydllamBcensedunderprrovtlonsofC
(commenc
APPLIANCES
RESIDENML ]OB OSRB'fON
thS,c .n7000) nfflheBusmssndPro(e.lon,Code,andmy
licenelelfarce And Affect. PANELS
License Cass L,.A
Date Cantnctor UP TO 2DO ANTS
ARCHITECT'S DECLARATION
101-1000 AMPS a
Q�u o o of I understand my pplanselse be used u public records. OVER 1000 AMPS F SQ.Fr.H-GDR AREA 5/9Q.17.
E 5 Llmnsed Professional SIGNSELFLTRICAL 4
«<<< OWNER-BUILDER DECLARATION SPECIAL CIl2C 4/-M 0
t.,
� Iherebyaflmtthat l am exempt from the Contractor'License Law for the ^ll
0 o following n.(Station 70315,Business and Pmfe®fona Code:Any city or / / /
�ZF' reasocounty which requires a permit m comtuct,alter,improve,demolish,or repair iFMP.M OR POLE IJSf�
'vi any structure priorwit Wuamealsorequbesthe applicant for mch pe into P00D610ES Ir`,_
ryG file a signed statement that he t licensed pursuant to the provbiem of the C I'//
Contractor's License 4w(Chapter9(commencing with Section 7000)o vi-V SWAtMLNG POOL ELECTRIC VALUATION
SOS sion3ofte0ualneas and Pro(embns Cade)orthat hetexempttheref m cad' -
0 the basis for the alleged exemption. Any violation of Section 7031 y G OVILETSSWITCI}F_SFIXTUR}5
appllrantfor a permit subjectethe applicant tot civil penslty of morel n
flvWundred dollars($500. NEW RESIDENTIAL ELECTR
I,as owner of the roe y employees �sr, STORIES TYPE CONSTRUCTION
property,rty,or he t m b es with w d r their sole
compeneaHoMwBldothe work and the stmtturet i ed or offered for�! u
O sale(Sec 7064 Business and Prefeasloro Code:The Contractors License taw,
t!j $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP HIS.UNITS
who duex uchwork himselforthrough hlwwn employees,provided that such
improvement are not Intended or offered for side.If,however,the building or TOTAL:
improvement issold wlthinoneyearofcompidioRtheowner-builderwUI have
ben of proving that he did Am build or Improve for purpose ofule.). QTY. PLUMBING PERMIT FEE
4 as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
ntratten to construct the project(See 7066,BualnessaM Pro(enWne Code•. PERMIT ISSUANCE
The ContnRori License Law does nut Apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
bull"or Improves themen,and who contracts for such ptojem with a FEE SUMMARY
cratfactor(s)licensed pursuant to the Conteors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under See. B k P C for this reason
CH�Tcl FIc MM.
DRAINS FLOOR ROOF,AREA,COND. SANITARY V N
. Owner Date Rp-Cppq p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
❑I hereby afllrm that I have a certificate of consent to selLinurc,ora RECEPr N
certl0catAZZker.'Compenzation Luuran¢ora celtlfed copy thereof(Sac. GAS EA.SYSTEM-1 INGp OUTLMS PARK FEE Y N-
3800,Lab CJ RECEIPT N
PolicyN
Com any GAS EA.SYSTEMAVER 4(EA) BUILDING DI VISION FF.ES
❑PCchiRed copy t hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Cenified ropy t filed with the city Inspection division.
CERTIFICATE OF EX MP"HON PROM WORKERS' GREASE TRAP PAID
INSURANCE
N4URANCE SEWER-SAMTARY-STORM EA.2001ar. Date RCC21 t#
(lhb section need nm be completedpermittforane hundred dollen
(slW)mlrsa') mce WATER HEATER w/vENr/Fa.EcrR ENERGY FEE Y N
I certify that In the perfoenof the work for which this permit t blued,
I shallnot employ any person In any manner ro u to becorm subjectto the WATER SY5rEM/TREATING
Workers'Compenution Laws of California,Date PAID
O Z Applicant NEW RESIDENTIALPLMR. SQF. Date Rece1 I#
Z O NOTICE TO APPLICANT:10fter making this Certificate of Exemption,you
Hshould bemnrubpct to the Wcolums Camperoathm pmvtlonsof the Labor TOTAL:
N Code,you at forthwith comply with such provisions orthts permit shall be -
W C deemed revoked. BUILDING FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I here6yaffl rm that there is a construction lending agency for the perfamt TOTAL: ELECTRIC FEE
D Z anee of the work for which this permit t Issued(ST.309'/,Civ.C.)
U O LendsrA Name PLUMBING FEE
LL h- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE A
OImrtllythatl havereadthtappgotionand datethattheaboveinformation
(U incorrect.I agmAto comply with all cityand ontetyordinancusand statelaws PERMITISSUANCE FEES PAID:
>- (A relating tobuilding constuction,and hereby authorizereprenentatives oftt
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTRRORADDTOMECH. Dale RCCei [#
(We)agree to save,indemnify an d keep harrJess the City of Cu Fenton
V against] Jiffies,ludgment,costsand expenses which may In anyway accrue AIR HANDLING UNIT TfOlO,ODOCFM) SUBTOTAL:
A gg s dCl Immneue cec ttM�a=ting of th permit.
I114ic, AIR HANDLING UN7T(OVER IO,ODOCFM) CONSTRUCTION TAX
Slgvfit..f Applicant/Contactor Dae IXl{AUST}{DOD(W/D[K:T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS ISCLOSURE
Will theappllcant or future bulldingoovpart store or handle hazardous HEATING UMT(TO 100,000 BTU) Date RcxCci t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Sedion2S532(a)7 HEATING UNTIE(OVER IOO,OOD BTU) OT .�
❑Yrs , �No 51
Will the applicant orfflure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAN TE
which emit haurdomalr contamlnsntas defined by the Bay Area Air NO rI I`.leaJ�
Quality Management District? BOILER-COMP OHPOR 100,000 BTI]) NO V `7 J
4Yea ❑❑No
have read the bazardeus materials requ lmment under Cha FIAT 6.95 of BOILER-COME(OVER 100,000 BTU)
the Califomt Health&Safety Code,Sections 25505,25533 and 25536. 1Clio I+ ICasn4or"t
understand that If the building does not currently have a tenant,that it t my NEW RESIDFNUAL MECH. SQ.FT --
responslblllty to notify the occupant of the requirement which moat be met
prior to issuance of a Certificate of Occupancy.
Owner or authorised a gent Data TOTAL: ISSUED BV:' V V9r7�'
OFFICE COPY