21408 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
' Building Project Identification - PERMITNO.
Building Address: // i
� '(o9ot hi Ln 10 F{1c�'k.r s. � 21408 .
s ante: one:
CITY OF CUPERTINO-BUILDING DIVISION A A
C l adarsName: uc.Na: APPLICATION /PERMIT �" ��
U BUILDING-ELECTRICA_PLUMBING-MECHAMCAL CATECARY'. CO OLa
ArcAit Engine Lk.No: - '
q�� e QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO '
Address: � 2� Uftr�l PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provision.of Chapter9(commen<- APPLIANCESRESIDENTIAL JOB DESC ON '
Ingwith Se on7000)of Divieion3ofthe Busimma dProfengmsCode,and my -
Iicense is in full force and effect. PANELS
Llcensc Class Lic.N
Date Contractor ,'(��/§�•.
ARCHITECTS DECLARATION 2014000 AMPS `/\ •� "1/
Q�u orO Zp I understand my plana shall be used as public records. OVER ILGOAMPS .IT.FLOOR AREA $/SQ.FE
kbLCA Licensed Professional - SIGNS ELECTRICAL -
z to<gu OWNER•BUILDER DECLARATION SPECIALC
!l4 Ihereby affirm that I am exempt from the Contractor's License law for the
oo following reason.(Section 70315,Business and Professions Code:
' G Any d or
TEMWPE.RM RFZ ' county requires to rstm ,alter, deolOEI TN co , mtoanystm=mpriortoaWance,alsorequimstheappBntfosuchreit
V file a signed statement that he Is licensed pursuant to the provisions of the
3 w0 t; Contredor's License Law(Chapter 9(commencingw(th Section 70011)of Divi-
SWEIIMINGC
sion3oflheBusinesendProfesslonaCode)orthathebemmpttherefromand VALUATION
y�y1 the basis for the alleged exemption. Any violation of Section 7031.5 by any 1 ,.
p0 applicant for a permit subjeeb the applicant to a civil penalty of nor more than OUTLETSSWITCHESFIXIURES
[�a five hundred dollars($500).
M 1,as owner of the property,or my employees with wages as their Bole NEW RFSIDENDAL ELECTR SQ'hT' S[ORIES TYPE CONSTRUCTION
HOcompensation,wllldothe work and thestructure la not intended or offered for
O sale(Sec.70K Business and Professions Code:The Contractors Licame Law
does not apply to an owner of Property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who dcessuch work himself orthrough his own employees,provided that such
Improvements are not intended aroffemd forsale.IL however thebuilding er TOTAL:
improvement swldwithlnoneyearofcompldlon,the owner-buildcrwill have
tlillZurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
(Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corstfuct the project(Sec 70K Business and Professions Code:
The Contractor's Limned Law don net apply to ea owner of property who ALTER-DRAIN&VENT-WATER(EA),
builda or improve.thereon,and who centracts for such p( -
ojects with a
anadFEE SUMMARY
or(s)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
OwnerDRAINS FLOOR ROOF,AREA,CONT. SANITARY Y N
Date RECEB7 M
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y 'r
QI hereby affirm that I have a i certificate of consent to selfdnemof ora RECE3PT M
cert(Rcab C.) rkers'Campensatlonlnsuranre oracertifled copythereof(Sec. GAS EA.SYSTEM-1 INCA
policy3800,Lah C.I PARK FEE Y_ N_
Camn GAS FA.SYSTEM-OVER4(RA) - RECEIPT c ti
� Y BUILDING DIVISION FEES
Certified copy la herebyfamished.the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certi(ied copy la filed with the city Inspection di4lslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE PAI )
(Thiacectionneednot bcompleedifthepemtUfaronhundreddollenSEWER&ANITARY-STORM EA 2WF{
Date Rewi t#
($10E)mleec'), WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cerfifythat in the performance of the work forwhich this permit is issued,
I shall not employ any person In any runner so as to become subject to the WATER SYSTEM/1REATING
Workers'Compensation Laws of California.Date - PAID
O Z Applicant
Z NEW RESIDENTIAL PLMB. SQ.FT, Date Recei t#
NOTICE TO APPLICANT:If,after making this Certiflote of Exemption,you
CC should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions or this permit shall be
deemed revoked. BU FEE
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
lherebyatermthat there is a construction lending agency for the perform Tp : LECTRIC FEE
Z once.fthework(orwhlchthbperMtisiseued(Sec.W97,Clv.C.) -
U O Iaader'.Name PLUMBING FEE
LL F 'sanders Address QTY. MECHANICAL PERMIT FEE ECHANICAL FEE
O W Imdifythatl have reacithis applicationand slatethattheabovelalmenatimt M
bcorrect.I dgmito comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} IL relating to building construction,and hereby authorize representatives of this
N city to enter upon the above-mentioned property for inspection purposes. ALIFRORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cu Perrino Date Reeel t#
V against Liabilities,jadgments,caalait)d expenses which may in any way accrue AIR HANDLING UNIT l0,W0 CFM) _ SUBTOTAL:
against sal tynconse�gye�l/i"i )Fhhe gr/yntinng of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
e�o�� / O
hare of Applicant ractor Date EXHAUST HOOD(W/DUCT) - - CONSTRUCTION TAX PAID:
5r
HAZARDOUS MATERIALS DISCLOSURE -
WillthespPitcard ala.definedboreCuprtfuture ino Municipal
Code, hapten Is 9.IZ a rdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
Health and
defined by the Cupertino Municipal Code,Chapter 9.12,and the;
I-Iealtha. Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes �I,+�.,1 No
lch emie appliha,car ou,air tombuilding occupant use the Bay Area devices VENTILATION FAN(SINGLE ftESID)' ISSUANCE DATE
whicheMtharardouaairrict?contaminants ore defined by the Bay Area Air '
silly Management District? - - BOILER-COMP(3}{I'OR 100.IXq BTU)
Ves ❑❑No
ave read Healthe h h
Safety
materials requirements 5533 Chapter 6.95 of BOILER-COMP(OVER 1fD,B00 BTU) p9
the understand
t Health building
Code,Sections25505,h veal and,than I II�� a'B
asponsi and that notify
the occupant
note require encs tenant,that It Lamy NEW RESIDENTIAL METH. SQ.Ff.
priori Issuance
roti ytheompantaftherequlremenb which must be met (1 8
priorialssuanceofaCertiflcateo(Ompanry. SEP
Owner or authorised agent
Data ISSUED BY: C+ I
TOTAL: �rptT—
OFFICE COPY