21896 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.en Identification PERMITNO.
Building Address: s 21896
woe sine Phone:
f�C�v , (U CITY OF CUPERTIN4BUILDING DIVISION Qt
cont n.ra am/e: Lm.N.: APPLICATION / PERMIT
"� /� BUILDING-ELECTRICALML BING-MECHAMCAL CA77:CARY CONIROI,p
Arc [tet/Engineer. k.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ 1:11:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am 0cenaed under provWonsof Chapter 9(cormneo< APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Secti.n7000)of Dlvisi.n3ofthe Buslness..d Pr fn,t.,Codgand my
license is In fu8l�99r�¢¢and dfect. PANELS
Wcense Class_(/J Lic.p ld L
Date'{—L�GI Contraaar U 2011000 AMPS
ARCHITECTS DECLARATION OVER 1000 TWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
nt0 Z I understand my plain shall W used as public records
O
.U6 Licensed Professional SIGNS ELECTRICAL
6 cW. OWNER-BUILDER DECLARATION
u, SPECIAL CIPiCU1T/MI9C
F, z, Ihercby af0rmtlutlam exempt from the Contractor's License law for the
Z pp following reason.(Section 70015,Business and Professions Code:Any city or
O`L " TEMP.METER OR POLE[NST.
KRIt"'� countywhich rcqubcsa perMttoconslrot,alteq Improve,demolbh,.rrepalr
�.a anystm=mprfortnlb iuuance,alsorequirestheappllantforsuchpermitto POWER DEVICES
Ofile a signed statement that he Is licensed pursuant to the provbiom.f the
u, Contractor's License Law(Chapter 9(no..eing with Section 700)).!DHT- SWIMMING POOL ELECTRIC
30 slon3of the Businessand Pro(e®LnsCode)orthat hebexemptlherefromand VALUATION
a the basis for the alleged exemption. Any violation of Se tion 7001.5 by any OUTLEISSWITCFFSA%TURES
applicant for a permit subjects the applicant to a civil penalty a nor more than
$� five hundred dollars($5001. NEW RESIDENTIAL ELECTRSQ.Ff. STORIES 7YPECONSTRUC'1'ION
.. ❑Las owner of the property,or my employees with wages as their sole
�7 Q, compensation,wllldothe work and lhestructure b not Intended or offeredfor
9 n sole tSoc 7044,B..I..and ProfessionsCode:TheContractor's License Law
j$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUT' RFS.UNITS
who doessuch work himself orthr.ugh his own employees,provided that such
improvements are not intended oroffered forsals.If,however,thebullding or TOTAL:
Improvement bsold withinoneyearofcompltiogtheowner-W 0derwill have
the rdenof proving that he did not Wed or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L_j ae owner of the property,am exclusively mntrating with licensed PERMIT ISSUANCE � �l
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's Llmnse Law clow not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such projects;with a FEE SUMMARY
gq66tt(T��ct (a)licensed pursuant to the Contractor's License Law.ec OUTSIDE FEES
r L.Jf,am exempt under SB k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP / SCHOOL TAX Y_ N_
❑I hereby affirm that I have a cemfiate of consent to self-Insure,ora l RECEIPT p
mtiBate ofWorkers'Compensation Insurance.,.milord copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
3800,[ab CJ RE-CEIPTM
Policy Y GAS EA.SY91"EM-OVER 4(EA)
Com acts 1 BUILDING DIVISION FEES
dcenlfled crcby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
,ijajkrtified copy b filed with the city inspection division.
CERTIFICATE OF EXEMI'TION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. DatC ReceI t#
(This ionneedriabecomplied Bthepermitbf.,onehundreddollars
%100)orless.) WATER HEATER W/VEM/ELECTR 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 m as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation Iawa.f California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
Z O NOTICETO APPLICANT:[Laftsr ma king this Certificate of Exemption,you
should become subject t.the Workers'Compensation provlslons of the Labor TOTAL:
f/) Code,you at forthwith comply with such provisions orthis permit shall be BUI
deem d revokd.
W 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. Z b W
Ihercbyaffltmthat them leading agency for the perform TOTAL: �(� ELECTRIC FEE
7 ance of the work for which this permit Issued(Sec.3097,Civ.C.)
02 lenders N. PLUMBING FEE Q
LL F lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U 1 certifythal l have read this application and aututhatthe above information
O W is rorrea.Ixgree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r (L relating to building ronstmNon,and hereby authorise representatives of this
(— Z city to enter upon the above-mentiond property for WpMion purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to ave,indermi and keep harmless the City of Cupertino AIR 7{ANDWNC UNIT(TO 10,000 CFM)
V a ainstllebi t4re,pdgment.7 and expense which may in anywayactue SUBTOTAL:
r city In segue ollMpsnt(ng.(thispemnit.
AIR HANDWNGUMT(OVEft 10,000CFM) CONSTRUCTION TAX
SI reed Applicant/C^ntmnor Date Da AI15'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFATINC UMT(TO 100,00)BM Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
lialth and Safety Code Section 25532(,)1 HEATING UNIT(OVER 100,000 BTU) TOTAL: Qs
[3 Yes NN.
Willthe applicant or future building occupant use equlpnant ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harerdousalr rontamhanteas defind bythe Bay Area Air
lity Management District? BOMER-COMP(3HP OR 100,000 BTU)
Li Yes nT�No n(k
a have read the hazam..matcrlalsrryuircrrcnb underCM1apler 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health h Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have.tenant that it is my NEW RESIDENTIAL MEC[{. SQ.FT.
responsibility to notify the occupant of the requirement,which must be
prior to Issuance of a Certificate of Occupancy. G ft
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE COPY