21534 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
BAddress:
I��f sty 21534
a
Owner. mr:
Phone:
APPLICATMINhUBIAIIIALUAIL
Q" M 170 421P l CITY OF CUPERTINO-BUILDING DIVISION
• c° an amr APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBING.MECHANICAL C/` R CONTR011N
A lmet/ gi.l.. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreta
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
I hereeetion 70that(amlcensedunder keBustrovlslonsof Chapter9(mnudmy APPLIANCESRFSIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)0l Divislon3eft eBuslnessand Profmsione Code,and my
license la ln!)tllf ewy/Paid effect. [ PANELS
Lirense Gla Ltd.if rs asaWlE
a.x
Date}/, ConneoUP TO 2DO AMPS
ARCHCS E �IIC I(}7 (`s'/I••1{.
201-1000 AMPS
ca 77, ]understand mypbmshalbeused aspublicrecords. OVERIODOAMPS SQ.ET.FLOORAREA S/SQ.FT.
a Z E Limnsed Professional - SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUfT/#LSC
Iherebyaffirm that l am exempt from the Contractors License law for the
OO following reason.(Semon 7031.5,Business and Professions Code:My city or
�Z�c9 countywhichrequiretapemdttocomtr d,altelimpmvedemolbh,orrepair TEMP.METER OR POLE INST.
anystmcture pdortoibbsuance,aborequireatheapplicantforsuchper tto
y 1 O file a signed statement that he b licensed pursuant to the peovBloa of the EWER DEVICES
Ou, 'Contractor's License Low(Chapter9(commencing with Section 7000)of DIA- SWIMMING POOL ELECTRIC
E, O then 3 ofthe Businms and Preesslom Code)or that he b exempt therefrom and VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by say
applieantfora permit subjectstheapplcard toe civil penalty o(nct morethan OUTLETSSWITCHESI•IXTURES
a five hundred dollars($500).
7 6 ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDEN7TAL ELFf_TR
SQFT. STORIES TYPE CONSTRUCTION
compensation,willdothe work andthestmcture b not Intended or offered for
5 ❑ sale(Sec.70K Business and Profesuma Code:The Contractors License Law
$$ does not apply to se owner of property who builds or Improves thereon,and
who doessuchwork himself wthrough hisownemployees,provided that such OCC.CROUP 615.I1[v'T75
Improvements are not intended orrefered forsale.It however the building or TOTAL:
Improvement bsold withinoneyeProfcompletlogtheowner-bullderwlll have
t"rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEEFLOODTDNE APN
"L as owner of the property,am exclusively contracting with licensed pQtMITISSUANCE
contractors to construct the project(Sec.704y Business and Professlom Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER H'.A)
Wilds or Improves there°#and who contracts for such projects with a
cty,does)Iimmed pursuant to the Contee ragor's Liwnx Law. gpCg FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under SB k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATIONRECEI'F N
1,�hereby Phren that I have a certificate of consent to self-Inhere,or a FIXTURES PER TRAP' SMOOL TAX Y N
ceNf(late of Workers Comperwtion Wuranm or a certified ropy thereo((Sec. RECEIn N
3800,Lab C.ja-�.a //1 y7 I� CAS F.A.SYSTEM-11NC.4 OUTLETS PARK FEE Y N
PolicyI C%Y"'�(t ��—G RECEM'N
Com anv `t11]iil ;Q CAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
�Cedifled copy b hembyth the cid. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
entified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
Glussecllonneed not becompleted lithe permit eforom hundred dollars SEWER-SANITARY-STORM E.A.200F7. Date Recei t#
($10))wlest3 ENERGYFEE Y N
I mnot (hat la employ
an person
in any heworkmanner
so as to b comeertnitb Ltsued, WATER HEATER W/VENT/F1.[CTR
I shall not employ any person ,r any manner ao m m become subject to the
O Worken'Compensatlon Lawn o(Californla.Date WATER SYSTEM/TREATING PAID
Applicant
Z OZ NOTICETO APPLICANT.If,after makingthis Certificateof Eaemptio,you NEW RESIDENTIAL P6MB.__SQ.FT. Date Recei t#
hshould bemmesubpect to the Workers'Compensation provisions of the Labor
WW Code,you=at foe hwlth comply with such provislom or this permit shall be TOTAL:
> deemed revoked. BUILDING '
CL c CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there b a construction Ieeding agency for the perform-
D Z ance ofthework forwhlch thin permit is beaded(Sec.3097,CIv.CJ TOTAL: !FEEA
IC FEE
UQ Ieaaara Name ING FEE
IL F leaders Address QTY. MECHANICAL PERMIT FE6 NICAL FE!Receipt#O W Irertifythatl have read this application and patethattheabove information
1 Ismm•et.Idgento comply with all cityand county ordinances and pate laws PERMUISSUANCE oZ�Z ID:T relating tobuilding comwRlon,and herebyawhoixempersentztivesofthbcity to enter uponted abovcmentioned property for impaction purposes. ALTER OR ADD IO MECH.
(We)agree to save,Indemnify an d keep harmless the City I Cupartmo e.galIabiltleligms,copedndexpenses whkhmayn ywayascrue AIR HANDLING UNIT(TO 1O,OW CFM) SUAL:
.gal aid CI 1 con u se°(the gra ting of this Pe it
,u J` AIR HANDLING UNIT(OVER 10000 CFM) - CONSTRUCTION TAX
Signatureof Appl+..n�/Contractor Date IXHAl1SI HOOD(W/DUCT) CONSTRUCTION TAX PAID:
V2A RDOUS MATERIALS DISCLOSURE
Will thcapplicant or future building Net store or handle hazardous HEATING UMT(TO 100,ODD BTU) u
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recoi t#
I With and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU)
El yea r]NO TOTAL:
Will the applicant or future building occupant use equipment or deviceszaVENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hardm
hazardous air coetarnnb as defined by the Bay Area Air
. Quality Management District. BOILER-CAMP OHPOR I00,DOO BTU) PAN
I Yes ( J No
Yesrtheth& cant matde.Se requimmentsunder Chapter, 1 of BOILER-COMP(OVER 100,000 BTU)
the Californiailnla Health A Safety Code,Sections 2550.5,2553;and 25539. 1 NN q
understand that ifthe Wildingdom not cumartly have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT. ��� NH 1991
responsibility to Issuance
to of
the occupant of the requirements which most be me!
prior to Lssuancc of a CcrtlBcatc of Occupancy.
Owneror authorized agent Date ISSUED BY:�/ yI//� 1/J V 1
TOTAL:
OFFICE COPY