21465 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prato t Identification PFRMITNO.
*ioLOC) N v 21465
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CITY OF CUPERTINO-BUILDING DIVISION ti
Coni* .n.Mme: Lie.No: APPLICATION /PERMIT I 20 .,C
BulLDING-ELECTRICAL-nuIvBTNG-MECHAMCAL CATEGORY CONTROL/
Architect/Engineer. Llc.No: b
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PEIMITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby
eeno"'mthat] iv BcenMN under eBusinemannsaf ChionsCo e,andm APPWANCFSRESIDENTIAL JOB DESCFNr110j
Inense 1.in fon force and effeon3olthe8uslnessand llvfnsionsCode,and mylicct PANELS -
Limm b In suit force and c.N
Llanse Chm Lk.Y J ��
Date Contractor LIP TO 200AMPS 00!)P—Op ✓V—�
An shall CTSDECLARATION OVER 10AMI'S
coo Z I understand my plans shall be used u public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ,FT.
O
ZF Licensed professional SIGNSELECTRICAL
Q uy� OWNER-BUILDER DECLARATION $PECWLCIRCNT/MISC
7Fo, Z Ihereby affirm that]cam exempt(romthe Comratare Llansc hwfor the
07 followingreaeon.(5ea1on7031S,Bu,in and Professions Cade:Anydtyor TEMP.METER OR POLE INST.
county which requlresa serMt loconstruct,alter,improve,deno8sh,orrepair
15gaQ any structure prior to Its L ance,afsorequorstheapplicant forsuch permit toPOWER DEVICES'
C U file a signed statement that he Is licensed pursuant to the provisions of the
Contnctorb License Law(Cha er9Section(commencin with Sion 7000)of Divi-
OO r^ Mlon3 ofthe Business and Pmfeab VALUATION
lonsCode)orthatt he exempt therefromand SWth1MINC FOOL ELECTRIC
H Qthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSMWHE&HXrLRFS
O applicant into permit subjects the applicant to a civil penalty of not more than 1
$ five hundred dollars($50(). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCTION
C]1,as owner of the property,or my employees with wages as their Mole
�7¢ compensation,will do thew ".it thestructure is not intended or offered for
D sale(Sec.7014 Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improve thereon,and OCC.GROUP RFS.UNITS
EE: whodoessuchwork himselforthrough hisownemployera,provided that such
Improvements are not Intended proffered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearofcompletion,the owner-bu llderwill have
I an of proving that he did not bund or improve for purpose of sale.), QTY. PLUMBING PERMIT FEE FLOOD MINE APN
e Las owner of the pmpeny,am exclusively contracting with 1—rued PERMTTISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who
Wilds,or Improves thereon, and who contracts, for such ptojecb with a ALTER-DRAIN&VENT-WATER(EM
o"tt etar(M)nrensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under SB&P C for that reasonOUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
• Owner 1'p
WORKMAN COMPENSATIONION Date RFCF3PDECLARATION FIXTURES PER TRAP SCHOOL I" Y_ N
F-11 hereby affirm that 1 have a rertl0ate of consent to self-Insure,ora RECEIPTN
certificate ofWorke Compensation Wu ora mrtiflel copy thereof(Sec. GAS FA.SYS17EM-1 INCAOITILEIR PARK ERS Y N
3800,Lab C.) RECEIPT x
Polley Y GAS E.A.SYSTEM-OVER 6(EA)
Com any BUILDING DIVISION FEES
Cetlfled copy is hereby furnished. GREASE./INDUSIRL WASTE INTEICEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' GRFASETRM PAID ,+_ �p
COMPENSATION INSURANCE SEWER-SANTEARY- Date Recei l# 33."cio
n
(fhissetion need not be completed If the permit b for one hundred dollars
(51 00)or less.) WATER F3FATQt W ENrL E41 Y FIE Y_ N
I cortlfy that In the performance of the weak forwhich this permit is Issued, I
I shall not employ any person In any manner so as to become subject to the WA.I.Qt SYSTEM/TREATIN
Workers'Compensation Laws of California.Date
ZZ Applicant NEW 'RESIDENTIM PI. ].�SQ to Recei t#
O NOTICETO APPLICANT:U,after making thisCertificate of Exemption,you
should become subject to the Workers'Compersatlon provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provisions orchis permit shall be BUILDIIIA
deemed revoked:
W F3CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
:) Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE
V 0 Lancer's Name
LL 1— Lende/a Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U IceNfy that]have rcadthisappliatlanand stetethat theabove information
O W Is correct.I agree to complywith all city and countyordinanco,iodstate laws PERMITISSUANCE FEES PAID:
r a relating to building construction,and hereby authomm representatives ofthis
(_ V) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupedino
V against llabilideq judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.gains aid City in rouse m cep ting of this perm°' AICONSTRUCTION TAX
R HANDLING UNIT(OVER 10,(X10 CFM)
Slgnaturcof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER GALS DISCLOSURE
Will the appbca nt orfumrc building occupant store or hand In hanrdous HEATING UNIT(TO 100,000 UM Date Recei t#
material as defined by the Cu petmo Municipal Code,Chapter 9.1;and the -
Health and Safety Cod e,Sction 25532(a)t HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑ Yes [Me
Will the applicant or future building occupant use etuipment or devices VENTILATION FAN(SINGLE RIESID) ISSUANCE DATE
which emit haeardom air contaminants as defined by the Bay Area Air
Quality Management Disdet7 BOILER-COMP PHP OR 100,00)BTU)
❑ Yes o r
Ihaveread thch out malerlals requirements under Chapler6.95 of 80ILER-COMP(OVER 1fX),fXp BN) �gC
the California Health&Safety Code,Sections 25505,25533 and 75531. I t/�J
understand that lithe building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FE.
rrsponsibllity to notify the occupant of the requirements which must be met �..j
Owner or ager Date ISSUEDBY:��Uf�'w
— TOTAL:
OFFICE COPY