21386 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemlflc.don - PERMIT NO.
Building Address: / ' n 21386
ours j" Y'J^ ons: /lM• ' /I A
APPLICATION
/ Z/MhMr�aV Asa-394,10 CITY OF CUPERTINO-BUILDING DIVISION
Cootractor'.Name: _ / r ue.N.: APPLICATION / PERMIT
D/Y i�LC d�FLcr�e VCD 7 BUILDING-FLECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL
Architect/Engineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO '
Add.. PERMITISSUANCE •121.. ®.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provWom of Chapter 9(commen APPLIANCESRESIMNTIAL JOB DESCRITTION
ingwilh Sectlon7000)of DlVl.io.3 ofthe Buslnessand ProfemlwreCode,and my -
license is in full to.and died. PANELS
Llrense ClasY„/(, Lie.N _
Dale Contraddoor�-
CHITECFSDECLARATION 201.1!100 AMP"'
0'LO Iunderstand^S'plain shallMussd.publicrecord-. OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
6
OWNER-BUILDER DECLARATION
C]
7F^ � Ihereby affirm that lam exempt from the Contractor's License law forthe SPFGIALCIRCUIT/MISE
following reason.(Section 70715,Business and Professions Code:Any city or
FH TEMP.METQt OR POLE INST.
� county which rcqulrc.a permit toconstruct,alteylmpmve,demolish,orrepalr -
.eymmeture primto its Issuance,also requiresthe applicant fw.u.h permit to POWER DEVICES
1 file a signed statement that he h licensed pursuant to the provisions of the "
SOSContractor's License Law(Chapter 9(comnr•ndng with Section 7000).f Divi- VALUATION
slon3ofthe Businemand Profemiom Code)orthathelsexempHherefmmand SWIMMING POOL ELECTRIC
$ the loafs for the alleged exemption. Any vldatlon of Section 7e3I.S by any � e'7 Sb L �1 10c)e W
O[TR.E755WITCHESFIXTURFS C
0 five hundred
red foraper rs($S . the appllcanuoadvll penalty ofnot more than n
five hundreddolhn( SN). NEW RESIDFNiIAI.ELFL7R SQFT,
STORIES TYPE CONSTRUCTION
o� �1,as owner of the property,or my employees with wages as their sole
Ccompensation,will do the work,and the stmctu re Isnot intended or offered for 4
'$a Ci sale(Sec.7064,Business and Pmfodlwss Code:The Contradoes License Law
q � does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.[11xgT5
Cw. who doeseuchwork himself orthrough his own employees,provided that such t �
improvements are not intended oroffmd forsale.If,however,lhebuliding'or - )� 4 TOTAL:
Improvement hsold withlnoneyearofcompldiontheowne>builderivill have -
! rden of proving that he did not build or improve for purpose.` Ie,). Q PLUMBNG PER IT FEE' FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed pFRMR ANCE
ntract.n to conslmctthe projM(Sea 7016,Bu.inemand Prolavdlons Code I I ��•o0 '
The Cootndo/s Llcenae Law dove not apply to an owner elf m sty wliu
I` AL 'DRgjhf le VENT-WATER(RA)
build.or Improves thereon, and who contract. for such p with,- w
dor(.)hcemed penutek to the Contract License Law. / FEE SUMMARY
�qB(�+ BACKF10W PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this/naeon +- .
DRAINS FLOOR ROOF,ABPA,CO D. SANITARY ,Y N
Owner ate N f. • RECEIPT 41
t [Z by WORKMAN I have.98ATIOND RATION- FIXTURESPERTRAP v w SCHOOLTAX, Y N
I Fere affirm that I have a certlfMate of onepnt`to.elf-Inwre,ora 4
cert)floate.fWorkers'Compereation Insurance aattlfledc9pythencef(See. CAS EA.SYSTEM- [NC.I OUTLETB PARK FEE YECEB'fa
3800,lab CJ
i I'allgpGAS EA.SY VER6(FA) 'RECEBTM
C..ny e.A.a en BUILDING DIVISION FEES
Certified copy h hereby ftmobe,L GR INDU LWASIE INTERCEPTOR PLANCHECI(FEE
�CerWied copy Is find with the city inspection dle I,loan.
CERTIFICATE OF EXEMPTION FROM WORKERS' R '7RAP PAID
t COMPENSATION INSURANCE -SAMTARY-SNRM EA.pOFT Date Rccx'i t#
(Thisoection need nor becompletedtfthe permit lafo..no hundred dollars "
(8100).rless.) ATERHEATERW/VENT/ELCTR ENERGY FEE Y N
I cent em t employ
any arson i an the caner so as to become
pesubjec booed, - —
I shall net employ any person In any manner so u to Mcome subject to 134 WATER SYSTEM/TREATING
Workerc Compematlon laws of Call(omh.Date PAID
O Z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Certiflute of Exemption,you NEW RFSID1dSITAl PLMB. SQFT. Date Reoei t#
should become subject to the Worker'Comperadlen provirus the Labor TOTAL:
N Code,you res at forthwith comply with such pmvWnnsorthis permit shall be ULD L t�
W > deemed revoked. -
4. c CONSTRUCTION LENDING AGENCY SEISMIC FEE L 3
I herebyafflrenthat there is a construction lending agency for the perform- ELECTRIC FEE - I.
Z - ance ofthe work for which this permit isb (Sn
euedc.3097,Civ.C.) TOTAL: , �`
'U O IenderaName PLUMBING FEE 2 Q7
LL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE (fo
Icertifythatl have mad this appBcztl.nand nate that theabove lnfortmtion
O W
1 Iscorred.l agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE �ZO OMSPAID-
} N relating to building construction,and hereby authorize representatives of this
Z etyWenterupontM a e.v erty
nlWnedpmpfwlmpectlonpurposs.. ALTIRORADDTOMECH. Date Reeel t#
V y (We)a e, lemnify an d keep harMem the City of Cupertino P
Beirut 11 1 ,jod nnte,conynd expenses which may In anyway accrue AIR HANDLING UNIT TO 10,000C1M) SUBTOTAL'
against y' onaequence of the granting dthh permit. -
AIR HANDLING UNIT(OVER 10,WDCrM) CONSTRUCTION TAX
Igmt Ap inns/Contrad.rl D,tD(HAUSTHOOD(W/DUCT) latxpp CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buddtngoccupant.wer.r handle hazard... HEATING UNIT(TO 100,000 BTU) Date RCCeI f#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
I ealth and Safety Code Section 25533(.)7 HEATING UNIT(OVER 100,=BTU) TOTAL:
�I Yes rj No
111 theapplicant or future building occupant we equipment or devices VGTIILATIONFAN(SINGLE RESID) ISSUANCEDTbTE
which emit haeardous air contaminant.a.defined by the Bay Area Air t(�-,,�fy�1p)Ljiy
Quality Management Dished? BOILER-CAMP C311P OR 100,007 BTU)
4 Yea �No' 'l'V v all
have read the hoz. ons rwleriala requirement,under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) IJ
the California Health A Safety Code,Sed Ions 75505,75533 and 75534. 1 (nI�/
understa nd that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. ,6s� -
responsibility to notify the occupant of the requirements
which=at be met I P4 ftnrsn7'{Ipw
prior to Issuance of a Cedificate.f Occupancy. - rIF
Owner or authorized agent Date ISSUED BY;
' TOTAL:
OFFICE COPY