21531 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building P,.'et Identification \\ TI PERMIT NO.
Building Address:?ge) G 21531
Phone: A
' �./. (.Q CITY OF CUPERTINO-BUILDING DIVISION
.�tCi'J IJ K�IIg71UC`t APPLICATION 1 PERMIT
ry { _ BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL a
QTY ELECTRICPERMIT FEE - BUILDING PERMIT INFO
PFRhIITISSUANCE ❑ El ❑
LICENSED CONTRACTOR'SD LARATION Ty
I herebyafflnn that l am licensed under provisions of Chapter9(romrvenc APPLIANCES-RESIDENTIAL JOB DESORPTION
l'ngwith Section 7000).!Division 3ofthe B..inessand Profession.Code and my
icense is In effect. I. / car PANELS
License affect.
a O V s1
Date Contract.
ARCHITE 201-1000 AMPS
re0 O I u darstand my plans shalt be used as public record& OVER 1000 AMPS 5Q.FT.FLOOR AREA $/9Q.Fr.
M U O Licensed Professlovl SIGNS ELECTRICAL
z
6 OWNEReBUILDER DECLARATION SPECIALCIRCUIT/M1SC
IherebyalOrmthatlamxemptfromthe Contratorb Llcense}aw for the
o qo following reason.(Section 7031.5,Business and Professions Code:An or
r Q rountywhlchrequlresapem ttommtmt,alter,lmprove,demolbh,or pair TEMP.METER ORPOLEINST.
anystructure prlorto its issuance,also requirmthe applicant for such permit o
O a file a signed statement that he is licensed pursuant to the pmvisiov of the POWER DEVICES
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
O� slon3ofthe Business and Profession Code)orthat he b exempt therefromand SWIMMING POOL ELECTRIC
VALUATION
4 � the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not morethan OUTLETS—SWITCHES FIXTURES
r. five hundred dollars(9500).
Q 7 OI,as owner of the property,or my employees with wages as their soNEW RESIDENTIAL ELECTR sole NEW STORIES TYPE CONSTRUCTION
co
< mpensation,wilidothe work,and thestructure Is not intended or offered for
9 0 sale(Sec.70x4,Business and Prefesslon Code:The Contractors License Law
�$ does not apply to an owner of property who builds or improves thereon,and
whodoeasuchworkhlmselforthr ghhisownemployees,provldedthatmch CCC.GROIP RFS.UMfS
Improvements are not Intended oroflered for sale.If,hmeeveq thebuilding or TOTAL:
Improvement is sold within oneyearofcompltion,the owner-builder wilt have
mepurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE Flpp ,OHNE APN
L-i L as owner of the property,am exclusively contracting with licensed pp R 1SSIlANCE
contractors to construct the Project(Sec.7044,Business and Professions Code: r�-
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT WATER BRA)
or Improves theeon,and who contracts for such projects with a
cgtSf+tor(s)licensed Pursuant to the Contracture License Law. gACK ROW PROTFLT.DEVICE FEE SUMMARY
L I I am exempt under Sec. B&P C for this reason BACK
Owner Date \ DRAINS FLGDR ROOF,A CON '��- SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEi Np
❑I hereby affirm that I have o lasurate of consent to opythem. (oraSm. PER ' SCIBOOL TAX Y N
c8W LateofWorkep Co pemuatlonlnsunnce oracertified ropy them.!(Sec. RECEIPT
3800,Lab CJ Q�JQa J� _ GAS FA.SYSI'FTt.I INC.40UTLE75 PARK FEE Y N
Paicy p_ B�/T� RECEB'I«
Com GAS G.SYSTEM-OVER 4(EA) BUILDING DI VISION FEES
ertiied copy V hercbyth the city GREASE/INDUSML WASTE INTERCEPTOR HENERGYFEE:
FB Certified ropyV riled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE
Rhissmlon need not be<.moltedlfthe permitLs!.Tone hundred dollars SEWER-SANITARY-STORM EA.200E 1', TO
G910o)ar lass.) WATER HEATER W/VENT/ELCCTR I camlythat in the Performance of the work forwhlch this permit is isauM,I shall not employ any person N any manner ro as to become subjet to theOWorkers'Compensation LawsofCalifornia.DateWATER SYSTEM/TREATING npplicantZ WTICETO APPLICANT:ILager making rhfsCMBiate of Exemption,you NEW RESIDENTIAL PLMB.__SQ}T,should become subject to the Workers'Compensation proebdom of the Labor
LUN Cade,you must forthwith comply with such provision orthb Permit shall be
> deemed revoked. BUILDING FEE
a p CONSTRUCTION LENDING AGENCY - SEISMIC FEE
= Z Ihereby affirm that them b a contrutlon lending agency for the perform TOTAL !AN ELECTRIC FEE
area of the work for whim thio permit V issued(Ser.3097,civ.C.)
Io L) laneere Name PLUMBING FEE a�
LL I<.dce.Address QTY. MECHANICAL PERMIT FEE
O W lcedifythatIhaveread thBapplicatlonandatatethatheabovelnformation MECHANICALFEE
a iscorrect.I agreeto comply wlthall cityand county oMinanas and state laws PERMIIISSUANCE FEESPAID:
} Nrelating to building contrution,and herebyauthodaerepresentativesofthls
I— Z city to enter upon the above-mentioned property for Wpetion purpose. ALTER OR ADD'TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeeiptll
aga tliabNties,jacigments,"sand expenses which may In anywayactue AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL-
MR
�t"I on ate eof eating a this permit.
AIR HANDLING UNIT(OVER t0,0D0CFM) CONSTRUCTION TAX
!n o App cant/ tractor etc EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building oerepantstore orhindle hirallous HEATING UNIT(10 100,000 BTU)
material ascieflned bythe Cupertino Municipal Code,Chapter9]$and the Date RCCej ill
IiEI yes Softy Code,Se Jloon 25532(&)1 HEATING UNIT(OVER 100,000 BTU) TOTAL-
fly
Wilithe applicant or future building oceupam use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE-DATE
which emit havrdous air com.nu enes as defined by the Bay Area Air
Iity Management Dt trlt7 BOILER-COMP DFP OR 100,000 BTU)
ux�Yes g No Od
Ihaveread the hazar`1i ous materials requirements under Chapter 6.95 of BOILER-COMP IOO,OOD BTU)
thn Calilornl.Health&Safety Cod,Setlons 5505,55.33 and 25534.I
understand that if the building does not turently have a tenant,that it t my NEW RESIDENTIAL MECH. SQ.}T �EC,� Y1990
reeponstbllltyton.tifythe antoftherequirements,e9—��K
`�
pr rtoissu cc
Ce
X' d
�11ner or authorized ag
TOTAL: ISSUED BY: v�
OFFICE COPY