21071 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PETNBTNO.
Building Address: /")vl 0
/L S" S 2 21
c ��n1ame: - we:
�WZ fy eue. CITY OF CUPERTINO-BUILDING DIVISION I L)
Contrartax.Name: 04 Na: APPLICATION /PERMIT
l.K I Ne/C
21911 71.1 91 BUILDING.ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lk.Na.
1110 — QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.: /Yz�Q PERMIT ISSUhNCE .()D �/{ ❑ ❑
LICENSED CONTRACFOR'S DECLARATION LCI
I herebyaffirmthat l amllcensed under provblonsoiChapterg(commen& APPLIANCES RESIDENML JOB DESCRIPTION
Ingwlth Sedion7000)of DiWalon3ofthe BusinessanciPmfessionSCode,and my
license is in full force and effect. PANELS n
License Clam Lk.M Paw—
I C
Date GHITEC( 701IODOAM r •w l�
ARCHITECT'S CTSDECLARATION OVERIODOAMPS SQ.FF.FLOOR AREA $/SQ.FF.
0 CCZ I understand my pisco shall be used m public records.
Licensed Pn>(essbrul SIGNS ELECTRICAL /�, L E ' N
6 OWNER-BUILDER DECLARATION P I E R
to] SPECIAL CIRCUIT/MISC
Zt, lhereby a(firm tbatlatm exempt from the Contractor.License Law for the
!.Vowing reason.(Section MIS,Business and Profemkns Code:My city or
O TDdP.METER OR POLE INST.
�,� county which mqulresa Permit[.mvrequia)ter,Impmve,demsuch,orrepair
mitto #tea. /��
anySwcture prior[olio Wuance,alw requkeatheapplcantfoe such perm([to POWER DEVICES DATE
❑k a slgnad atatement that he le llcensed pursuant to the provisions of the
Contractor's Licesselaw(Chapter9(commencing with Section 7000)of QQ30 Divi- SWIMMING POOL ELECTRIC ~'sion3ofthe Sudnnsand Protessioss Code)orthathebexem themfromand VALUATION
Cthe basis for the alleged exemption. My Violation of Section 70315 by any OUTLET&SWITCHFSFIXTURES
���WGWGWGiii
applicant fora permit subjects the apphcantto a civil Penalty of not nnrethan
Ove hundred dollars(SM. NEW RESIDENTIAL ELECTR
❑Lasowner.fthe property,or my employesswith wagesastheLr wk �'�' STORIES TYPECONSTRUCTION
7.4 compenmtlon,wlldolheworkandlhestructure Issue intended or offered for
0 saL(Sec 7064,Business and Professions;Code:The Contractors License Taw
$$ don na apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who doessuchworkhimaellorthmugh hisown employers,pmvidecithat such
Improvements are not intended oroffered formle.If,however,thebuilding or TOTAL:
Improvement.sold withinoneyearafcompletb4the owner-bullderwll have
t4c.tiurdeno(provlagmathedid rutbuldmimpmve(rnpurposeo(sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
L f L as owner of the property,am exclusively contracting with licensed
cootncton 1.construct the project(See 7014,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License law does no apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
bulhis or Impswes thereon,and who contracts for such pipocts with a
ogp(Factor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec w
B&P C far this rean
Owner Date DRAINS.FLOOR ROOF,AREA,GOND. SANITARY RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXIURES PER TRAP SCHOOLTAX Y N
❑IM1ercby a(llrm that I have a certificate of consent to self-Insure,or a RECEIPT
N
moo'llb.fWorkers'Compereatlonlruunnm or a certified copy thereo!(Sec. GAS F.A.SYSTEM-1 INC.4OUTIETS PARK FEE Y N
3800,Iib C.)
Policy N RECEIPT#GAS EA.SYSTEMOVER 6(EA)
Cam any BUILDING DIVISION FEES
OCenified copy is hercbyth the cid. CREASE/INDUMRL WASTE INTERCEPTOR PLANC14ECK FEE
copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE9RAP PAID
COMPENSgTION INSURANCE SEWER-SANRAAY-STORM EA 700FI Date Receipt*
(Dissections, na ba completed Ithe permit is forone hundred dollars
(5I00)mlsss3 ENERGY FEE Y N
I cartify that illthe part.— the work forwhich this nn Is Issued, WATER HE3�W/V�/Q'�TR
I shag not employ any ymannerwss to lectdothe Wp•I.Di SYSTEM/TREATING, PAID
-
0
Compenaatlo wno lifomia.Date 77�r
O Z Applicant TINEWREADENTIALPLMe. SQF. Date Recei t#
Z O NOTICE TO APPLICANT:Ila er nuking this Certificate of Exemption,
shwld become Subject to the Workers'Compensation provbioro o(the Labor TOTAL:
N) Code,you must forthwith comply with Such Frovbiona orthb permit shall be BU
ILDING FEE
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
d O I himbyaffirmthatthere is a construction lendingagenryforthe Perform- TOTAL: ELECTRICFEE
Z an,
oftheworkforwhkhthb permit b issued(Sec.3097,Civ.C.) PLUMBING FEE
L.) O )ender.Name
U. F Lender'.Add.. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W •I mrtllythat l have readthieepplicationand statethattheabove Information FEES PAID:
b corms.l agree tocomply with all city and county ordinances and state laws PERMIT ISSUANCE
} a relatingtobultdingcorutructlon,and hereby authorize representatives ofthb
H N city p
to enter upon the abve-
omentioned property for Inspection purposes. ALTTRORADDTOMECH.
Z Date Receipt#
_ (We)agree to and keep harrtdem the Clty o Cu rthra
against liabilities g s,w sand expenan whkh ma
Ina wa mus AIR HANDLING UNIT TfD 10,000 CFM) SUBTOTAL:
against said C In eT,r a of the granting d this permit
..} AIft HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signa ppBcan Contractor,55 to f/ amAus'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
illtheappllcantorfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 RTU) TOTAL:
E] Ye.
Will the applicant orfumre building occupant use equipment or devises VENTILATION PAN[SINGLE RESID) 'ISSj 1 DATE
which smut hamrdws air contamlrunts as defined by the Bay Area Air w�
Quality Management DisMct7. BOILER-COMP OHP OR 100,0(0 BTU)
4Yes o
bava read the hazar ous miderl s requirements under Chapter G95 of BOILER-COMP(OVER 10),000 BTU) nnT
the Gilfomh Health&Safety Cod, loss 2550.5,ti53J and 75536. 1 Y71t/
understand that if the bulldl of currently have a tenant hat itis my NEW RESIDENTIAL MECH. SQ.FT
rnporulblllty tonaify th m of the requirements whi must met - /y�.�
prfortobsu� I a Occupancy. co capft
/D 9
Owner scam dagent Dm ISSUEDBY: l
TOTAL:
OFFICE COPY