21026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21026
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era are
COhh% 2 44 -�68gA A
CITY OF CUPERTTNO-BUILDING DIVISION
c°^o-aeor.wme: LIc.N°: APPLICATION / PERMIT �•^ 6� r
ArehbM/Engineer. Lic.N. �Lqq BUILDINGELECTRICALPLUMBING- E HAMCAL CATEGORY CONTROtgz
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ E:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPLIANCES RESIDENTIAL JOB DESCRIPTION
Ingwlth Section7000)of Dlvbin3 ofthe Buslnessand ProfensionaCode,and my
license Is In full force and effect. PANELS
License Class L
Date Contractor UP TO 2DO ANTS
ARCHITECT'S DECLARATION 201-]000AMM
rc Z I understand my plans,hall be used as public records. JOVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
X� Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MLSC
L., Ihereby affirm that am exempt from the Contractor's License Law for the
FO
70..qqqqq��y following reason.(Section 7mi.5,Business and PmfsaAom Code:Any city or
ZS3 county which requires permit tocommoct,alter,improve,demolish,orrepair TEMP.MEEK OR POLE INS].
�a°.J any structure prlorm its Issuance,also requlresthe applicant forsuch permit to
Oilk a signed statement that he is licensed pursuant to the provisions of the pOlygg DEVICES
Contractor's License Law with Section 7000)of 8Divi- SWIMMING POOL ELECTRIC ao� sl°n3oftheBusnessandPrefenl°mCode)orthatheItexempttherefromand VALUATION
a S^S the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS9r4TCHESFIXFURIS
aa: applla foray rmitaubectsthe applicant tootivilpemltyo no more than _
five h dyed dollars(5,500). NEW RESID �E TR .
,as owner of the property,or my employees with wages as their sole �'M1T' Oq
PECONSIRUCTION
C < mmpensation,wBldotMw rkandthestmmm boot intended or offered for
❑
sale(Sec.7W41,Business and Professions Code:The Contractors License Law does not apply to an owner of property who builds or Improves thereon,andS.UNITSwhodonsuch w°rkhimself orthmugh hisownemployees,provided that suchimprovements are notIntended oroffered forsae.If,however,thebullding or DAIS TOTAL:mprove ntbsoldwithinoneyearofcompletiomtheowner-budderwlllluve ofpmvingthathedld not build or improve for purpose ofsaleJ. QTY. PL GPERMIT FEE "
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7016,Business and Professions Code:
The Contractors License Law don not apply to an owner M property who ALTER-DRAIN&VEM-WATER(Ell)
bu Bov
ds or Impres thereo , and who contracts for such pW)a a with a
cq[Ltractor(a conned pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Seg. B&P C for this reason
7, — OUTSIDE FETS
OwnerADat ��Fr DRAINS.FLOCK ROOF,AREA,GOND. SANITARY Y_ N_
3V KMN COM SATION DECLAR ION / BE=#
01 hereby affirm that I have a mrtlficate of consent to self-nvre,or a FD( �s
TPER TRAP SCHOOLTAX Y_ N
certifiam of Wmken'Compensation Insurance ora certified copy thereof(Sec. RECEIPT'N
3800,Lab C.) GAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N
Policy N RECEIPT N
Com any GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
ffCcrtified ropy b hereby furnished.
❑Cettified copy is filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE I
CERTIFICATE OF IXEMPFION FROM WORKERS' GRFASE7AAP PAID
COMPENSATION INSURANCE SEWERSAMTARYSTORM F.A.200FT Date Recel t#
(Ihbtectnn need nes be completed lithe permit b!carom hundred dollen
6100)or Immid th WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
]certify that tithe performance ofthework forwhlch this pertNtbIssued, —
I shall not employ any person in any manner no as to becorre subjea to the WATER SYSTEM/TREATING
wurkers'C°mpematnn Lawaorf Cahfornia.Date PAID
Z NOTICE
rat after NEW RESIDENTIAL PLMB.
Z O N0710ETOAPPLje&to
eWorkeraking s'Com er ationiateof Exemption,Labor
��FI'. Date RTA [#
H should ode,yo =a aurthwit the ply with
such provisinprovhis permit
s Gbor TOTAL:
W rimmed
rmstlmlhwith comply with euchprovisiom orthB pemNt shall be
W > deemed revoked. BUILDING FEE
CL ° Iherebyafirm that themhes construcION t niNG entlng agency for the perform SEISMIC FEE O
Z ancooftheworkforwhichthbpermit boneed(Sec.3097,Cle.C3 TOTAL: ELECTRIC FEE
(� O lender's Name PLUMBING FEE
IL LendersAddrea QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
O W Icetlilythatlhave read thbapplicatlonand sta(ethattM1e Anwamformatlon
1 is correct.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. fn relating tobeilaingcomtructlon,and hereby authorim repressmativesofthe,
F Z City to enter upon the above-mentioned property for Inspection purported. ALTERORADDTOMECH.
— (We)agree to ave,indemnify an d keep harmlev the City of Cupertino Date Receipt#
agallot liabilities,pediments,cost,and expenses which. in any wa'!L x AIRRANDLINGUMT(TO10,000CFM) SUBTOTAL:
agaI tsald yfr'a sequence of the anon tape 't.
nom_ AIR HANDLING UNIT(OVER 10,0DO CPM) CONSTRUCTION TAX
Sigmtu Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle havrdous HEATING Uh77(70100,000 BTU) Date RBCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 2S532(a)7 [iFA71NG UNIT(OVER 100,OW B'IU) TOTAL: .�
❑Ya �No
Will the appliantorfuture building occupant use equipment or devims VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air PAID C
• Quality ManagementDistrid? BOILER-COMPOHPOR100,U(D BTU] PAID
PYes ❑F�'�No
h read the hazarRi mad,lals requirements under Chapn,6.95 of BOILER-COMP(OVER 1MD00 BTU) _
the Californla ITeaBA&Safety Code,SevtleodZ5B5,25533 and 25534.1 SEP 1990
undcmtandthatifthebuildingdwsnmt rrently,haveatenanLthatllismy NEWRESIDFNIIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Ocmpa nry. City of{f rone-hon i
Owner or authorized agent Date ISSUED BY: N ( t
TOTAL
OFFICE COPY