21453 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Retains Project Identification PutiMITNO.
Building Address:
boo s& e4uIV ,re. 21453
737.777ante p
_ rm Throe Rvd Z6$- 4&57 CITY OF CUPERTINO-BUILDING DIVISIONIC I?-I
Contractor's Nara: Lic.N. APPLICATION / PERMIT
BUILDING-E.ECTRICAI.PLUMBINC-MECHANICAL CATEGORY CONTROL N
Architect/Englraer. y�y.� Lk.No:
0- �ar�3� .?3 QTY ELECTRIC PERMIT e�F'E.sE�, BUILDING PERMIT INFO
Address: Z0,07,09 �F'OSP�r.� D s/Vx 74. PERMIT ISSUANCE 1:1LICENSED CONTRACTOR'S DECLARATION I�J
I hereby affirm that l am bcensed under provisions of Chapter 9(commenc APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Sc tion7000)of Dlvlsion3ofthegusinessand Pretrial on.Code,and my
license Is In full fora and effect. PANELS
License Class Lic.N
Date Contractor UP TO 2DOAMRS
ARCHITECTS DECLARATION 20I-10DOAMIS
q�+mMmX I understand my plans shall be used as publicremrds. OVERIOOOAMPS SQ.Fr.FLOOR AREA S/SQ.FT.
Fe L Licensed Professional SIGNS ELECTRICAL aG //J
OWNER-BUILDER DECLARATION l SPECIALCIRCUIT/MISC ['71 JJJ T
1p., 7 IherebyafRrtn thatI am exempt from the Contractor's License Law foe the �J
7 g_Q following reason ISection 7011.5,Business and Rofe cdons Code:Any city or TEMP.METE4 OR POLE INST.
0"' .o ,)ty hichrequlresapermitwmmtmct Oter,lmpro edemolbh,orrepalr
`'10 -Q anystructure prior to its issuance,a iso requires the a ppllcent for such permit to (OWER DEVICES
K�U file a signed statement that he is licensed pursuant to the provisions of the
�Oc' ContracmrsLicense Law(Chapter 9(rommencingwith Section 7000)ofDivi. SWIMMING POOL ELECTRIC VALUATION
O sion3 ofthe Business and PrefessionsCode)orthat he is amm thercfromanl a.�
u�65 thetads for the alleged exemption. Any violation of Section 70315 by any UTLETSSWITCHESEX•TURES `)(GO � _' ,tQ
[b, appBant fora permit aubj lstheapp@ant too civil pevBy doa
nor mthan 5 o G^ _{,
a five hundred dollars($50N. NEW RESIDENTIAL ELECTR
.. ❑I,as owner of the SQFT. STORIES TYPE CONSTRUCTION
property,orhaemploymwithwagesrtheirsole
7a compensation,wWness.do the work,andthes Code:Th.ructure is C.ctot d.ended License
Law
�O d for
saie(Scc 7056,Buainaaand Professions Code:The Contractmrs License law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
0.0. whodoeasuchwork hlmueBorthrough hsownemployers,provided thatsuch
Improvements are not Intended oroffered forsale.If,however,the W ilding or TOTAL:
improvement 6sold wlthinoneyearofcompletionthe owner-bullderwlll have
�en of Forcing that he did net bund or bnpmve for purpose ofsale.). QTY. PLUMBING PERMIT FEE Ff.ODDZONE APN
L as owner of the property,am exclusively contracting with licensed PFRMHLSSUANCE
rims on to construct the project(Sec.7614,Business and Professions Code:
Contractor's License law does nor apply to an owner d property who
Wilda or Improves thereon, and who contracts for such pkojects with a Nr11 m.Y.'
CgDlTactor(s)licensee pursuant to the Coneractor's Lianas law. FEE SUMMARY
BABACKFLOW I'ROT D LCR,
LJ I am exempt under Sec. B k P C for that reason
DRAIN^r FTOORr— 111TI
�ROD SANITARY Y N
. Owner Date RECEIPIN
WOfiat COMPENSATION DECLARATIONERE SCHOOL TAX Y N
EI,hereby aRirm rm ththat I have• Insurance
a c of consent to opythemof ora RECEI'T N
certificate00, ab ofWorkers'Comperoatlonlrouvnceaaar<I(ied ropythemof(Sec. CAS EA.SYSTEM-1 INCA OUTLEtc 'J PARKIg Y N
3800,Lab CJ
'RFLIBI'f p
Policy N GAS EA.SYSTEM OVER 4(EA) BUILDING DIVISION FEES
Com any
ffCrkfi; ropy la hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy 6 flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t# , 0
(This section need not be completed tithe permit 6 for one hundred dollars
(SIM)or less) WATER HEATER W/VENT/dFGTR ENERGY FEE Y_ N_
I certify that in the performance of the work forwhlch this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Lawsof Callfornla.Date PAID a^�
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t# ✓7a�
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Z 0
F N should become subject to the workers'Compensation provisions of the Labor TOTAL:
Code,you roust forthwith comply with such prov6lons orth6 permit shallbe BUIL LNG 1�
W > deemed reemked.coNsrgucrlDN LENDING AGENCY SEISMIC FEE a
CL O Ihereby affirm that there 6 a mmmictlon lending agency for the perform TOTAL: ELECTRIC FEE 2
7 Z ane"of the work for which this permit 6 taxied Cec.3097,Civ.C.) a
02 Lender's Name PLUMBING FEE
LL F- Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE a
0 W Icortifythat l have read this applicatlonand statethat theabove Inform tion
CL 6correct.I agree to comply with all city and county ordinances andstatelaws PERMIT ISSUANCE ��e'23' FEES PAID:
r rclating tobuilding construction,and hereby authodve reprosentatives ofth6
I- 2 city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. aQQ
_ Date Receipt#
(nst)agree to save,Indemnity and keep harmless the City of ay acermo KIR HANDLING UNIT(TO 10,000 CFM)
0
againstliabilities,n consequence of the
expen es which may In anywaya ue SUBTOTAL:
againstm City In consequence of the ming m(thla permit.
1111q,
AIR IIANDWNGIATf(OVER IO,ODOCFM) CONSTRUCTION TAX
Sig reof Appli /Contractor Da Id EHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will the applies rat or future building occupant store or hand In hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Code Section 2553I(a)? HEATING UNIT(OVER 100,OW BT) TOTAL:
❑Yes M No
Will the applicant orfohma building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazanIms air contaminants as defined by the Bay Area Air
.0 Qu a lity Management District? BOILER-COMP OHP OR 100,=BTU)
4Yea No
have readthehazaous materials requirements under Chapter 6.95 of BOILER-COMP(OVER I O0,000 BTI) PAO
the California Health k Safety Code,Sections 8505,23533 and 75534.I
understand that if the building does not currently have a tenant,that It is my NEW REST DENTIAL MSCI I. SQ.FT
responsibility to notify the occupant of the requircrrcnts which most be met w
prior to Issuance of a Certificate of Occupancy.
Owner or authotired agent Date ISSUEUp
Y :1.L1�n 1 Irq
TOTAL:
OFFICE COPY