21674 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B°°ding Address: 21674
Aa yod MG<NI +rill � vx
e.s Cm
aone. APPLICATION
S /ms:� CITY OF CUPERTINO-BUILDING DIVISION I I q I
Coneractm'a Name: LIB.No: APPLICATION /PERMIT l
AW
CATEGORY CONTROL 8
ArcMt / glnecr /I LIe No:
$% BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: Zo 4C90 Mart ^ ✓ PERMITISSUANCE CO ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pmvidom of Chapter9(comearm APPLIANCESRMDENf1AL JOB DESCRIIPITON
ingwlth Sedton7000)of D vision3ofthe Businessandprofesstone Code,and my
license is In full forte and effect. PANES r•p �-. 1-(�
License Cha LkN l
Date Contractor —UP TO 200AMPS
ARCHITECPS DECLARATION 201.1000 AMPS
Q'L I understand my plans shall be used as public record& OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
OC
d t�uj Licensed Professional SIGNS ELECTRICAL
fnaG OWNER-BUILDER DECLARATION 2 SPECIALCIRCUIT/M1SC
f.,L�j/ Ihereby affirm that l am exempt form the Contractor.License law for the
Z 0=1 following reason.(Section 70031,5,Business and Professions Code:Any city or TEMP.METER OR POLE INST. ' CO
- - LED
4,, countywhichrequimsapemttommtmd,alter,Impmve,demoltsh,orrepAr
anystmcture prlorto Its Issuance,also requirestheapplicant for such permitto POWER DEVICES I - T E R
yd file a signed statement that he is licensed pursuant to the provisions of the
OUTS I DE FEES
Owl Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC ATI
30 elon3ofthe Businessand ProfessiomCode)orthat he h exempetherefromand DATE ON
VSectiony�Sn S the basis for the alleged exemption. Any violation of Section 70115 by any OLI LETSSWITCHES.FIXI.URES
syr applicant for a permit subjects the applicant to a civil pemlty ofnot more than
five hundred dolhm(S500). NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
7 Q I,as owner of the property,or my employees with wages as their sole
cdmpcnsation,wtlldothe work,andthestmMm h not Intended or offered for
p
In(Sec 7066,Bustness and Profeaioes Code:The Contractors License Law
$$ doe not apply to an owner of property who builds or improves thereon,and OCC.CROIIP RIS.UNITS
who don suchwork himself or through his own employees,provided that such 'Ja
m
improvements are not intended or offered for sale.If,however,the building or TOTAL: Iso
improveent issold within oneyearofeompletion,the owner-buliderwill have
t burden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I_I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
comnractoto mmtruct the project(Sec 7064,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon, and who contracts for such p0ojects with a FEE SUMMARY
cgWador(s)licensed purmanttothe Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECENT N
WORKMAN COMPENSATION DECLARATION pD(TURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a certifimte of consent to self-insure,or a RECEIPT N
certificate o(Workeni Compemationlmurance,cess certified copythimof(Sec. GPS EA SYS-TEM-i ING4 OUTLETS PARK FEE Y N
3800,Lb C.) RECEIPT N
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any
ffcertmed copy In hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city Impedion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Recci tic
(This section need not W completed if the permit h forom hundred dollars
(SIW)or lea.) WATER HEATER W/VEYI'/ELECTR ENERGYFEE Y_ N_
I certify that in the performance of the work forwhich this permit is issued,
1 shall not employ any person to any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESID1 AL PLMB. SQFT. Date ReceI tTf
Z O NOTICE TO APPLICANT.I,after making this Certificate of Exemption,you
Pshould become subpot to the Workeri Compersation provislom of the Labor TOTAL:
LO Code,you must forthwith comply with such provisions or this permit shall be BUILDING CC j deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby afftrmthat there baconstmctton lendingagency forthe perform- TOTAL: ELECTRIC FEE
7 Z ruce ofthe work for which this permit t,hsued(Sec.3097,Civ.C.) PLUMBING FEE
02 IendersName
F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W 1 renifythat l have read thisappBrationand statethat theaboveinformation
O
a Is correct.I dgree to complywith all cityand county ordinamosand state laws PERMIT ISSUANCE FEES PAID:
r relating to building construction,and hereby authort,ro representatives ofthb
I— Z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMICH. Date RecelptT!
(We)agree to save,Indemnify an d keep harmless the City of Cu pertino V PIR HA UNIT l0,W0 CIM)against liabilities,judgments, and expenses which may In any way accrue SUBTOTAL:
agai Id C' to con ce mf th tinting of this permit.
/3 AIR HANDLING UNIT(OVER IO,000GF.M) CONSTRUCTION TAX
mturcaf Applicant/ ientracter JJDate EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA2lARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HPATING UNIT(TO 100,000 BTU) Date' Reuel ted
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Safety Code Section 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea MN.
Will the applicant or future building p.et use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which e Manageoxid airDistrict?
cats as de0ned by the Bay Arca At, RAW
QualitYnMamgcrcnt DbtnNo7 BOILER-COMP(3}I'OR 100,000 BTU)
4havereadthebaaal7�ousrstedaismqutme nbunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) �I G 5 *LpgOt�
the California health&Safety Code,Sedio x25505,25533 and 25536. 1 JAN lot -'x
understand that if the building does not currently have a tenant,that it is my NEWRMDENMALMFCH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
prior toissuaoceofaCertificate of Occup&my.
Owner or authodud agent Date TOTAL: ISSUED BY:
OFFICE COPY