21845 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification PERMiTNO.
Bn l ndas: DK. �� a t 2. a� 21845
hong A . S h A A
a CITY OF CUPERTINO-BUILDING DIVISION
cont.tor'.Name: - uc.Na: APPLICATION / PERMIT
k b`f CATFAORY COhTROLX
BNIAI NGELECTRICALIR.UM01 NGMFL}1AMCAL
_ Ambltect/Englomr. LIc.No:
IC PERMI'C"'� FEE BUILDING PERMIT INFO
t, ELECTR
Adtlreac PERMITISSUANCE O
LICENSED CONTRACTORS DECLARATION
I Wrebyaffirm that lism sW3ofunder Busuen andPrfCltaptee9cleand c APPOANCESIiF^SIDENITAL JOB DCtiCRR'DON
Ingwith5edfon 70007of it affect.
oftheaualnegand ProlegioaCode,and my
license b In full(once and effect. PANF]5 IT',G-7 s c
License Clan LICK
Date Contractor
ARCHITECT'S DECLARATION 201-1000 ANTI'S
Z Z I understand my plana shall be used a public records OVER IODO AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
d
O
0 Licensed Pregdonal SIGNS ELDCTRICAL
<� OWNER-BUILDER DECLARATION SPFCIALCIRCUIT/MISC
3 I hembyalurrnthat I sou exempt from the Contractor's License Law forthe
following renan.(Section 70115,Buslnesind Emfeglons Cnde:Mydlyor TEMP MECpR OR POLE INST.
=nrywh4hmqubes,permhtomnm Malter,)mprove,de=Wh,ormpalr
y ay..=.pel wiu Lovaice,.iomq.b th..ppH.tforsuchp.r Itis POWER DOCS
L file a signed statement than he is licensed pursuant to the provisions of the
OSCommences License Law(Chapter 9(mmmencingwith Secdon7000)of DIW- SWIMMING POOL ELECTRIC
dun3 of the Binding and ProfeslonsCode)or that he b exempt themfromand VALUATION
9 the hash for the alleged emmptkm. Any Violation of Section 70315 by any OITILETSSWITCFffSFIXNRES
m� fi=Buotfor delta. mbjectsthe app Want too dull p<nakydnot moat than
(iv undmd ddWs(5500). NEW RESIDENTIAL ELEC SQ}T. STORIES TYPE CONSTRICTION
2< UL g owner of the Property,or my employerswith wages aslheb sole
mmpawtlon,wBidothework andtheamorgure is rout Intended or offered for
❑ sale(Sec 70K BuaInessand Pmfeslons Code:The Contractor.license Law
3$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RES.UNITSwhodoomehwoekhm lforthroughhisownemployees,prvvWedkhatredo
Improvements art end Intended oroffered Waste.If,however,thebulWing or
Improvement bsold wit oKyearofcmnpletlon,lheowner-bu0derw have �.
tl1S,Wedanof proving that Fix did not Wild or Improve for purposeofale.). CITY. h .., "PI:UMB C MIT' �' FEE.-' FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with 11¢nsed PERMIT ISSUANCEmntnctvn to mnswtl the project(Sec 7066,Buelnen and Emitted..Code:
The Contractors License Taw does ret apply to an owner of property who
Wilds or Improves thereon,and who mntnm fee such pioXCs with • ALTER-D IFA r^
cBt[+ctoRs)Rmved pursuant to the Contractors License Law. *_rt- -FEE SUMMARY'.
LJ I am exempt under Sec B k P C for this reason BACK FIA O CEOUTSIDFFIEES
Owner Dane DRAINSFIAO F.AREA SANRARY RECEIPT
WORKMANCOMPENSATIONDECLARATTON FDCIURPFR SCHOOL TAX Y_ N_
❑I hS amby aBirm that 1 have•certlfica ,of consent to artf-Insure,or a RFGE]Pf X
certUvteo(Weirkers Cmnpensabon Insurance or a certified copy thereof Sec. GAS EA. -1 ING60 PARKFFE Y N
W0D,Lab C.) RECEIPT X
pop's GAS EA.SYSTFTd-0VER 4(FA) BUILDING DIVISION FEES
.Ned copy b hercbythMahed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS CRFASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT Date Remi t#
(Thlssection need not be complated Bthe permit is for ons rs
hundrod dolla
(5100)mlm.) W,A.� .�W,/VENT/pyp�pR ENERGY FEE Y_ N_
I rectify that In the perforanceof thework forwhich this permit is Issued,
1 shall not employ any person In any manner ao g to become abject to the WATER SYSTEM/TREATING
Worlixn Compensation Laws of California.alifor .Date PAID
Z Applicant NEW RESIDENIIAL PIMB. SQFf. Date Remi t#
NOTICE TO APPLICANT:If,a#er mating this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the labor TOTAL:
N Code,you mut fort hwith comply with such provisions or this permit shall be BUILDING FEE
j decreed mo ked. SEISMIC FEE
C CONSTRUCTIONLENDI,NGAGFNCY
I hereby affirm that them is a construction lending agency for the perform TOTAL: ELECTRIC FEE _
Zane of the work for which this permit is,Issued(Sex,3097,Cm.Ca PLUMBING FEE
O lander:Nair
1— Lander',Adding QTY.' - MECNANICALPERMIT" 'FEE" MECHANICAL FEE
U I mrtifythatl have readthbapplioHonand gate that t1mbove Infomutim 1 L� FEES PAID:
1 is cored.Iagrect.comply withal]dryand munryorddnancesand state laws PFRMRISSUARCE W
W relating to building mnstrvctlon, ed herebyauthetrbe mpm e,.tives of tots
V) city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. Date Receipt#
(We)agree to save,indemnify an d keep harmless the City of Cupertino AIR HANDLING IR.Tf(TO 10,000 CFM)
agawt WbNth, dgmenta mats radexpenseawhlchmayinanywayaccrue SUBTOTAL:
.gaimtsaid(D mnsdqucg the gra ing of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
.2 — Is c� CONSTRUCTION TAX PAID:
5 v Applicant/C or Dale EXHAUST HOOD(W/DI)CT)
HAZAI D SUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,WO BTU) dDate Recei t#
miterlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑Yes MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE,DATE
which emit hazardous aur contaminants as defined by the Bay Area Ale
Quality Management District? BOILER-COMP DM'OR 100000 BTI.
�IYea rl No p/y ems.
have read the hav ous materials requirements underChapter 6.95 of
IlorCaBOILER-COMP(OVER 100,000 BTU) ii'!_Otl
lifornia Health A Safety Code,Sections 25505,2593 and 25536.I a,,
understand that if the building does not currently have a tenant,that it is my NEWRESIDFNTIALMECH. SQ.FT � ���
responsibility to notifys
the occupant of the requirement&which roust be at 1 '
Peter m teniae of.Certificate of Occupancy. ' �('!1j��/
Owner or authorired agent Date TOTAL: ISSUED BY'V
OFFICE COPY