21264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingMI
Project Identification PFRTNO.
enualnB Add . �TPt Ol0 HOK �� D
21264
�3 _
OIL (1 CZS It.'` CITY OF CUPERTIN66UILDINC DIVISION AL DATE
Contract° sName, � T�-.• jT-�., { Lk/.NI S APPLICATION / PERMIT 1
'Q ftN�j � w Q eo:` " BUILDING-ELECnUCAI PLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/ glneer. I.I.No:
QTY ELECTRIC PERM IT FEE BUILDING PERMIT INFO
Add. - PERMATISSUANCE '/ice 1:1 El 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(oamumc APPLIANCESRESIDENTIAL JOB DESCRI'TION
tngwlthSedion 7000)of DivisEm3 ofthcfluelnessandl§ sl...C.dgandm ,Il P-WC —
licen.elelnfuBy�TeandeffeR, a PANELS N1�VSQ
License Ch® (i A- LI.N �I
Date Contractor UP TO 2DO AMS
ARCHITECPS DECLARATION 201-1000 AMPS
re0 ZO I understand my plars shag be used as public records.
OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
dLlcenaed Professlowl SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION
C'a,� SPECIAL CIRCUIT/MISC
Z t.,Y1 I hereby affirm that I.....pt from the Contract.(.License Law for the
Qq�y following mason,tSection 7031 S,Business and Profeubes Code:Any dry or
F 47 county which requires a permit to corutmh,alter,improve,demolish,or repair TEMP.METIRORI'OLE INS(.
7 any structure prior to to Issuance,also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisbv of the POWER DEVICES
3u, ContraRor's License Law(Chapter 9(mmmencingwith Section 7000)ofDivi-
k,�Os sion3ofthe Buslnc.aand Profeuiou Code)orthatheeexempttherefromand SWAfhING POOL ELECTRIC VALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
O applicant for a permit subjects the applicant to a civil penalty of not more than
flue hundred neroftheprdollars . NEW RESIDENTIAL ELECTR SQXT. STORIES TYPECONSIRUCTION
❑I,as owner will
the a work a,or my employees with wage as thele sole
p compensation,70 R.A.and Pr f i.mthe Code: h not Wended or License
d for
Law
$ O sae(Sec 7014,to alnowandf property
Code:The Centnaor
sthereee Law
don not apply to an owner of property who n cads or improves and OCC.GROUP RFS UNITS
as
who doementsawork Mmrelf dedor.ugh his ownemployees,howevr,thebded thatauch ding or
improvementsarenot Intended earofco formic.len If,hower-b lkler illhave TOTAL:
improvement beold withinamycarofcomplctbry Iheowner-W Bderwlll Tuve
OiLlIurden of proving that he did not build or Improve for purpose ofsate.). QTY. PLUMBING PERMIT FEE
Lj 4 as owner of the Property,am exclusively contracting with licensed Fl-OODTDNE MN
contractors to construct the project(Sec.70K Business and Protrude.Code: PERMIT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ALM-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojects with a FEE SUMMARY
151cto(s)licensed pursuant to the Contractors License Law.
e am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
r`u ITSI OF FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
• Owner - Date RECEII'(M
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby orke that I have o lesura to of consent to copy
theure,ora RECEPT N
certificate ofWorkere'Compeuatlonlluurancemacertified copy thereo((Sa. GAS EA.SYSTEM.1 INCA OUTLETS PARK FEE - Y N
Sob,Lab CJ RECEIPT p
Pollq M GAS.EA.SYSTGf-OVER 4(EA) BUILDING DIV] FEE
Com any - S
ertiBed copyIs hereby famished. GREASE/INDUSTRL WASE INTERCEPTOR PLANCHECK FEE
CenNed copy Is filed with the city Inspection dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE "EWER-SANH'ARY-SIDRM EA.b10FT. Date R¢OCI [H
(Thlssectlon need not becompleted tithe permit u forom hundred dollars
($10(foeleu.) WATER HEATER W/VENT/ELFCTR - ENERGY FEE Y N
I nrtifythat In the performance of the work forwhich this permit is Issued,
1 shall not employ any person In any manner so u to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California.Data PAID
0 Z Applicant NEW RESIDENTIAL PLM B. SOFT. DRI¢' Recei Ifl
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you..I forthwith comply with such provision orthIs permit shall be B 6^4 On
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE .O
d Ihereby affirm that them bacoutrualonlending agency for the perfarm ELECTRIC FEE
7 Z Lada,the work for which this permit la bound(See.3097,Civ.C.) TOTAL
(� O Iender9 Name PLUMBING FEE
r Lender'.Addeasa QTY. MECHANICAL PERMIT FEE
O W 138hlfythatlhavereadthlsappllotlonanddatethatiheabovelnf..tion MECHANICAL FEE
1 iscomed.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building censtmctl.n,and hereby autbu representath"s afthla
Zetytoenteruponthe e-mentbned pmpertyf rspZion purpose. ALTFRORADDTOMECH. Date ReCel 111
_ (We)agree to ,I emNty an d keep barythi ;.. it.
City of Cupertino P
attained leblll b,costeandex nseaylnanywayaccme AIRHANDLING UNIT(I'OIO,000CFM) SUBTOTAL:
ag.bate b enge aft l o
LADLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
gra m Applica ontnctor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS TE ALS DISCLOSURE
illthea ntorfumrebull 1 occupant store or handle hazardous ITEATINGUMT(TOIOO,ODOBTU) Date RCCei [II
mater efinedbythe Cupertino unlcipai Coda Charner9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTR) TOTAL:
❑Yes No
Wllltheapphauder uture building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) 1i68ilATiCE DATE
which emit harardous ab mutamkarata a defined by the Bay Area Air J3=
llity Ma®gement District? BOILER-COMP OEIPOR 100,000 BTU) t _
4 Yea N
have read the has mismatehats requirements under Chapter 6.95 of MOILER-COMP 100,000 BTU) uy[ ✓pp
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have.tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which=at bents �� I
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL 'ISSUED BY: —"
OFFICE COPY