21391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruett ldemlficatlon PERMIT NO.
°""lgsdgo ERw wA-Y 21391
ncra rr one: A A A
A1YO" 2S3-24o CITY OF CUPERTINO-BUILDING DIVISION �q
Contractors Name He.No: APPLICATION I PERMIT �—r7� l(•j
BUILDING-ELFCTMCAL PLUMBING- F HANICAL CATEGORY CONTROL N
Amhltect/Engineer. Lk.No:
/ p ^�„ '^ QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: l o js ' L�r W- K0 PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DG "RATION
I hereby affirm that l am licensed under provbions of Chapter 9(mmmenc APPEANCEB.RESIDENTIAL JOB DFSCRIPTLON
Ingwith Sect1on7000)ot D3vtalon3o1lhe Bustnessand ProfesslonsCode,and my
license lslnfull force ande.affect. PANELS FJf7 w ry�aN )n F
License Cless le.IF VVV--K!�"t OFF
Date GHITECr ,.� CJ is. .-C U V��,J,J0.'
ARCHITECTS DECLARATION OW AMPS
m0 0 1 understand my plans shag be used ns public records OVE OVER 1000 AMID$ SQ.FT.FLOOR AREA
5/SQ.FT.
ti X Licensed Professional SIGNS ELECTRICAL
L
6 Odom eBUILDER DECLARATION SPECiALCIRCUIT/MISC
Z I.., 2 Iherebyafflrmthatlam exemptfromthe Contractors LlcenwUwforthe
following reason.(Section 70315,Business and Process ors Code:Any city,or
F�I"u� county rcqubeaapetmittommtmd Otegimprove,deenlish,ormpalr TEMP.METER OR POLE INST.
<g anystruciure prior to its beuance,aLsorcqulree theappncznt forsuch permit to
2?OµU file a signed statement that he is licensed pursuant to the provisions of the
TOWER DEVICESµ� Contractors License Law(Chapter 9(commencing with Section 7000)of Dwi- SWIMMING 100E ELECTRIC
H�05 alon3 oflhe Business and ProfessionsCods)orthat hebexempttherefromand ATION
o the basis for the alleged exemption. Any violation of Section 7031.5 by any 5COUTLETSSWITCHFSEKNAFS X3
applicant a permit subjects the applicant to a dvil penalty of not nnrethan
n,$ five hundred dollars(SSW). NEW RESIDENTIAL ELEC
TR
? ®I,as owner of the pmperty,or my employees with wages u their sole cSQFf. TYPE CONSTRUCTION
C ¢ c6mpereation,wWdothe workandthestructurcbnm intended or offered for
j sale(Sec.7044,Business and Pos esslons Code:The Contractors License Law
does not apply to an owner of property who builds or Improves themon,and
C who doessuch work Nmselforthrough his own employees,provided that such RES.UNITS
Improvements arc not intended oroffered formic.If,however,thebuilding ce TOTAL: /
Improvement esold within oneyearnfeompietion,the owner-budderwlll have
t rden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE. APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mvec truct the project(S 7064,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pRojecb with a
egn4ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I aq.pxempt ypde,SeC 0 h P C for this reason
IOUTSIDEF
Ow^er�) , )~^^�\ D t DRAINS FLOOR,ROOF,AREA,COND. 5ANrl'ARY Y_ N_
'�WpAKMANC FNSATIONDECLARA RECEIPT#
❑1 hereby a that I ha cort30czte of consent to selFfirsam,or a FDnURES-PFR TRAP SCHOOLTAX Y N_
cealticeteofWorkers Comperoadon InsuranceoramAifie copythereof(Sec, RECEIPT'#
380,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Poli N
Com any GAS IP
FA.SYSTIM-OVER LFA) RECEIPT CM
copy b hereby famished. BUILDING DIVISION FEES
❑Cedffied copy b filed with the city Inspection dlvbion. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhlssection need nee bec"mpleted if the permit Ls(oronshundred dollars SEWER-SANITARY-SNEM FA.200FT. Date Reoei t#
(dl Icamless.) WATER HEATER W/VENT/Q-ECTR ENERGYFEE Y N
I ll not employ
o anf Lemon I any
work for tobec mpermit b leaved, —
1 shall not employ any person In any manner so as to become subject to the
Workers Compensation laws of California.Date WATT sysrEnt/TRFATINc
Q Z Applicant PAID
Z O NOTICE TO APPLICANT:If,after making thio Certificate of Exemption,you NEWRESIDENIIALPLMB. SQ.FI'. Date Reoei t#
should become subject to the~ mWorkers'Compensation pmvbiom of the Labor TOTAL:N Code,you must forthwith comply with such provisions orths permit shall be
W > decad revoked. BUILDING DING FEE
CL 3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a constmctlon lending agency for the perfurnf
Oance of the work for which this permit is Issued(Sec.3°97,CW.C.) TOTAL: ELECTRIC FEE
(� L.endars Name PLUMBING FEE
U. L) an crabythatl QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iced.Iareeto c ready with all dtyndcourand tethattheabove In stateless
1 brormct.lagrceto comply with allcityand countyordinanmand state laws PERMIT ISSUANCE IZ•co FEES PAID:
} fArelating to bullding construction,and hereby authorize repreaentatives of this
1— Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD'#MECH.
— (We)agree to save,3ndemNfy an d keep harmless the City of Cupertino Date Receipt#
against liabilities,jadgmems,"sand expenses which may In anywayacenm AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agalns id Cityl osryu ce of the granUngaf this permit.
)90 AIR HANDLING UNIT(OVER 10,M)CIND CONSTRUCTION TAX
Sigrvmu ofA nt/Contractor to -- EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUSM IALSDISCLOSURE
Will the applicant or future build paMstoreorhandlehazardooa / HEATINGUMT(TO 100,000 BTU) q��
material as defined by the Cupertino Municipal Code,Chapter 9.17and the Date Recei t#
Hcallh and Safety Code Section 25532(a)i HEATING UNIT(OVER 100, ,000 BTN
❑Yes �No TOTAL:
Will the applicant orfmm Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) [-1$Qll�l'?JCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
L
nagement Dbtrlct7 BOILER-COMP OHPOR 100,000 BTU) NOVIp
v�p6�No IV 0 Is7J�
ad the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,0M BTU)
nia l lealth h Safety Code,Sections 25505,25533 and 25534.1
that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT p
itytontsifytheompant ofthe rcquimmentswhkh must be cart CitV L`F r)gnq�nn
ua fa rtincateof0. panty.
teed agent I Otte `
TOTAL: ions ISSUED BY:C\��
OFFICE COPY