21692 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B.iidingpddreas:
21692
one: p p
C /7GlELG,f Z,� -OZ/3 CITY OF CUPERTINO-BUILDING DIVISION
C°ntattoraNam: LIc.No- APPLICATION / PERMIT
-GY/ GffG� Cam '&Re
BUfLDINGELEC'[RICA4PLUMBINGMFCHAhTCAL CATEGORY CONTROLX
Archltett/Engineer: Lk.No:
�1y � QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addms:///� */n�Q� U � �0 PERMITISSUANCE
1�,� LECI ❑ ❑
LICENSED CONTRACEOR'S DECLARATION
I hereby affirm that l am Licensed under prwtslonsof Chapter 9(commene APIaLiANCESRE5IDENTIAL JOB DESCRIIrIION
ingwith Section 7000)of Mi sion3oftheeuslnewand PmfesdonsCode,and my
license is in full In and effect Y�/�3 PANELS
Lio,,t
Yls-
Lk.p 4�
Date � ContractorUP TO 200AMP-S
ARCHITECTS DECLARATION 201-IODOAMPS
FQ!M C7z I understand my phres shall bs used u pub8c records. OVER 1000 AMPS ae+s 5Q.F7.FLOOR AREA .At�$//SFT.
E (s Llcomed Profeseloml SIGNS ELECTRICAL v� Y�Q.pQ.cZ
OWNER-B UILDER DECLARATION SPECIALCIRCUIT/MISC
lhercbyaf8rm that lam exempt from the Contractor.License law for the
70...'� followleg re..(Section 7031 S,Business and Professions Code:Any city or
OZt-u9 ir TEMP.METER OR POLE INST. -
F4 county structure
requimsa Maupersncommtmuire.the aprovgdemolbh permit
to
q .s anystrucWre prior to ib Luvance,al�requlrcatheapplicant forsuch permit to P
OWER DEVICES
E O g file a signed statement that he is licensed pursuant to the provieom of the
Contract°r's License Law(Chapter 9(commencing with Section 7")of Divi- SWIMMING POO
ELECTRIC
��� slon3ofthe Business and Professions Code)orlhat he isexempttherefromand VALUATION
g �^�] the basis for the alleged exemption. Any violation of Section 70115 by any rs �T
OUTLETSFSWITCHES ,�.ayy�1 tV( s•JV
appllantfora permit subjects the applicant to civil penalty dna morethan t W
We hundred dollars($SOm. a
..�, ❑I,as owner of the property,or my employees with wages as their sole RESIDENTIAL ELITTR SfOf0E5 TYPE CONSTRUCTION
compensation,will clothe work,and thestroaure is not intended or offered for
5 O Is(Sec.7014,Business and Professlons Code:The Contractor's License Law
does not apply to an owner of property who Wilds or improves thereon,andOCC.GROUP IUMTS
who doessuch work hlmself orthrougle his own employees,provided that such
Improvements arc not intended oroffered for sale.I{however the W ilding er TOTAL: 1
Improvement issold within oneyearofcompletim,theowner-bWlderwill have
to rdco ofpmWng that M did not build or improve for purpose ofsals.). QTY. PLUMBING PERMITFEE HADD ZANE APN
Lj{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
the Cont rector's License Law does me apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such ptojeM with a
T[cto4s)Berried pursuant to the Contractor's License Law. FEE SUMMARY
f am exempt under See. B &P C for this reason BACK FLAW PROTECT.DEVICE OUTSIDE
Owner Dee DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECEIPT WORKMAN COMPRNSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self-msurc,or a FDCrURES-PER TRAP SCHOOL TAX Y N
certificate of Workera'Compereation Insurance ora certBied copy thereof(Sec. RECEIPT N
3800,Lab C.) GAS EA.SYSTEM-1 INC./OUTLETS PARK FEE Y N
Policy X RECEIPT X
Co any GAS PA.SYSTEM-OVER d(FA) BUIL RECEDING DIVISION FEES
[Hied copy is hereby th the ed.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Plied ropy b filed with the city impettion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Ihissectlonneed net W completed iftheperrot isforone hundred dollan SEWER-SANITARY-STORM E.A.200FI. Date Recei t# It.4
(9100)or l..)
Ierrtifythat in the performanceofthework forwMch thhpertrdHsissand WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I shall na employ any person In any manner to e,to become subject to the WATLR SYSTEM/TRFATING
Workers'Compensation Lawn of California. Date -
O PAID
Z Applicant
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you NEW RESI DENTAL PLhi6. SQFL Date Recei 0
should become subject to the Worloi s'Compereatlon po viuom of the Labor
w~ N Code,you most forthwith comply with such provisions or this permit shall be TOTAL:
> deemed revoked. BUILDING FE QS
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby affimr that b a construction lending agency for the perform TOTAL: ELECTRIC FEE
ante of the work for which this permit b leaud(5ec.3097,Civ.C.) I k0a
U T.cndds Name PLUMBING FEE
IyH IrndcAadrtss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I
O W ceitidi(ythaH luvemadthb appliutbnand statethattheaboveinfomemn
CL Is correct.I dgme to comply with all city and munty ordinances and slate laws PERMIT ISSUANCE FEES PAID
} N relating to buildingconstructon,and herebyealimlae representatives ofthls
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertlro Date Receipt#
againsWabilities,Ydgeonin,mus and expenses which may In any wayacems AIR HANDLING UNIT(To IgaoO CFM) SUBTOTAL:
againstsai yin cgpi quenre thegran ^g ofthls permit.
e AIRHANDUNGUNITroVERI0,"CFM) CONSTRUCTION TAX
igm of Applic / ractor pate*` EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZA OUS MATERIALS DISCLOSURE
Will the applicant or funim building occupant store or handle havrdous BEATING UNIT(TO I f1,000 BTU)
materul as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Ile❑ yes ❑
althand Safety Code, o
Sectlon25532(a)7 HEATING UNIT(OVER l00,000 RM TOTAL:
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS �ATE
which emit hazardous air contaminants as defined by the Bay Arca Air „`-r+'�`/
Quality Management theh Dag - BOILER-COMP OHP OR lOgO(D BTU)
Yea ❑Nn .,VAN & 31981
havemla Health
Sere Code,materials 25505, 5533underaChapter. 1 of BOILER-COMP(OVER100,000 BTU)
the Califomla Heahh&Safety Code,Sectlom 2550.5,25533 and 25531. I
understand that lithe Wilding does not currently have a tenant,that it k my NEW RESIDENTIAL MECIL SQ.IT.
roor to is lity to notify the occupant of the rcqubementswhich most be rret
prtortoiss a ofd Certificate of fthernrec // f=it xS LSfit lA lis
rauthorlu v 'p
J Date TOTAL: I ISSUED BY`:VS-/tea'f 1"`-' V "`^�—mss•
OFFICE COPY