21872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification - PERMIT NO.
Build Ing Aadreaa: 0/& 6/NDA 75fiA }�I 21872 Z
- pinrgaNi
ame: one:
Sod'k oAA) ;b8,d?.f3- CI TY OF CUPERTINOBUILDINGDIVISION q r
Ic.Na. APPLICATION 1 PERMIT
7, 3 BU DING-ELECTRICALPLUMBINGMSCHANICAL CATEGORY CONTROL#
Architect/Englna Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ tK ❑
LICENSED CONTR under SDECLARATION
IhthSy tlrmthat fDiviM=30ftheBuid visions end PrfChlonsCocommrn APPLIANCESRESIDENTUL JOB DESCRIPTION
It...11.fon force and dfaon3oflhe8ustneseand ProfesnomCode,and my
license is In full fora and eic.I - PANELS
LlcenecCtss Cont C �`1 M `C-�
Date Contnctar �L`
ARCHITECTS DECLARATION 201-IODOAMES
07- Iunderstnd myptroahalbeusedespub0crecorder OVER IBM AMPS SQ.PT.FLOORAREA � $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
In a SPFGIALCB2CUIT/MLSC
X F'- owing ratBrm5ecti n731.5,Businnth.ess
Crdoad Professions
License Law fort he
qq (allowing rcawn.(Section 7Qa15,B..Iness end Professions Gds:Any city or
F f'ny aunty which rcyuWa permittocorouct,alter,Unprove,demolish,orrepair TFA1P.METER ORPOLE INST.
'
OO '..73 anystmmmpdortoltsl mance,alwrequimstheappllantforsuchperMtto POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
3w� Contradols License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
#,SOS sion3 oflhe Bustessand Professl..Cade)orthat he is exempt theafromand VALUATION
Gthe basis for the alleged exemption. Any vldatlon of Section 70315 by any OUTLEISSWITC ES
applicant for a permit subjeds the applicant to a civil penalty of not more than
five hundred dollars($500).
FIL as owner of the property,or my employees with wages as their win NEW RESIDENTIAL TR SQFT. STORIES TYPE CONSTRUCTION
7 compensation,wBldotMwork,andthestm=m Isnot intendedor offered for
O sale(Sec 7066,Bunross and Professions Code:The Conmact.e.License law
$ does not apply to an owser of property who builds or Improves thereon,and OCC.GROUT' RES UNITSwho does suchwork himself orthrough his own employees,provided that such
improvement are not Intended oroffered fasak.If,howovep thebullding or TOTAI:
improvement tsold within one yearofcompletiaRlhe owner-bulhlerwlll have
tl)Lkurdenofpmvingthat he did notbulldorlmprovefapurpowo!role.). QTY, PL11aGPE FEE FLOOD 7GNE, APN
LJ L as owner of the property,am exclusively contracting with Ilanacd
contractors to construct the project(Sec.7044,Business and Profession Cede: PERM A
The Contractor's License Law does not apply to an owner of property who AL Vim, W (FA) al
Wilds or Improves Merron,rod who contracts for such pct
rojes with, TERFEE SUMMARY
.gR{(ador(s)11...dpursuant to the Contractor's Lim..Law. BACK FfA PROTTCT. E
LJ I am exempt under Sec B 4 P C for thin reawn
Owner Data DRAIN RROOF,AVA GOND. SANITARY Y N_'
RFGEIPT
�. WORKMAN COMPENSATION DECLARATION SCI l00L TAX Y N
❑I hereby afflmn that 1 have a certificate of consent to self-Insure,or a ARES'PER TR'aP O• �� Rp_FS.T.
cenifimteofWorken'CampensationIro mnaaaceAifiedcopythemof(Sec.
3800,Lab CJ GAS EA.SYSCEM-1N OUTLETS PARK FEE Y N
Polley p RECEIPT NGAS EA.SYS EN-OVEJt (EA)
Cam any BUILDING DIVISION FEES
�Cardind copy t hercbytumecity CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
lhed
I�CedNed copy t filed with the city Inspection division.
"K CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissection neednct becomplded Bthepermit tforone hundreddollars SEWER-SANITARY-STORM EA.]DOFF. Date Revel t#
($I D3)ol leas.) I WATER HEATER W/VENT/I9.FGTR OV ENERGY FEE Y N
I certify that In the performance of thework forwhlch this Permitt Issued,
I shall not employ any person In any manner an an to become subject to the ' WATER gVS�p�/TREATING O PAID
Workers Compensation Laws of California.Date
O Z Applicant NEW RESIDENTIAL PLNB. SQFr. Date Recel t#
Z O NOTICE TO APPLICANT:],after making this Certificate of Exemption,you
1" should become subject to the Workers Compensation provisions of the Labor TOTAL:
V3 Code,you moat forthwith comply with such provtbns or this permit shall be
W G deemed revoked.
BUILDING FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
lherebyaffirm that there t a construction lending agency for the perform- TOTAL: �0 ELECTRIC FEE
M Z once ofthe workfor which this permit In Issued(Sec.3097,Civ.C.)
02 finder's Name PLUMBING FEE D
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1mrttfythatl haveread thin appliationand statethatlheabuveinfmonatlon
CL twrrcdeo
.lagrtocomply,with alldtyand courayminanceand d nate laws PERMITE'SUANCE FEES PAID:
N relatingtobulldingconstmdim..dhembysuthorizerepresentativoofthas
city to enter upon the above-mentioned property for impedlon purposes. ALTER ORADDTOMECH.
Z Date ReCel t#
V _ (We)agree to ve,Ir d fly an d keep harmless the City of Cupertino P
against Ila es,ju ment,wns and expenseswhich may In anyw accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agains Id CI consequence gran ng of thio penult.
J.G AIR HANDLING UNIT(OVER IB0DDCFM) CONSTRUCTION TAX
Signatureo(A /Contractor Pate E%HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AlARDOUS MATERIALS DISCLOSURE
Will the applicant or futurcbdOding occupantstore or handle hazardous HEATING UNIT('10100,000 BII) Date Recel l#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyCade+—Sedion25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: E
C111Yes _I No
111 the applicants More building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSPJA�?I(,T1epATE
which emit hazard...air contaminant as defined by the Bay Area Air �+(` VU
Quality Management Dbtrld? BOILER-COMP(3HP OR 100,000 BTU)
Yea ❑No F E 9 2
haveread teeth&Safe's Code,aection rcrrenro5533 aChapter6.95 of . BOILER-COMP(OVER 100,000 BTU) 61991
the Gltand t Health b Safety Code,Sections 25505,25533 a t ands,that I
understand that itthe bulldingdcea notmmnlly have atenanL that lttmy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met /1��ra,r.�/1��sstr{
prior to issuance of a Certificate of On paocy. Yary E'J WPsa.
Owner or authorlaed agent Data TOTAL: ISSUEDBY: ��YL✓CG
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OFFICE COPY