21941 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PER!,IT NO.
Building Address: 21941
`�Ol-too o-caa e.1R
Phone: A
4\/\)A CITY OF CUPERTINO-BUILDING DIVISION �� ®
Contreetors Name: LIc.N. APPLICATION I PERMIT C�
Architect/Engineer. Lk.Na:
BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre.: PERhllTISSUANCE F-1 11LICENSED CONTRACTOR'S DECLARATION
I hehSacdo ivn that lam licensedunderBusli stialomof Chapter9(commmc APPLIANCES-RESIDENTIAL JOB DFSCR[I"HON
Ince.isI fell force
Businessand PmfesalonaCode,and my
Lic lus la In full force and effect PANELS I s
Data CV. LICM 1
nateCITECIr
ARCHHITECTS DECLARATION 00 AMPS
OO]. I understand my plans shall
OVER
be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
�y O
Licensed Profe.lonal SIGNS ELECTRICAL
U�ED
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC , y
p., y lhercby affirm that iam exempt from the Contractors License Law for the
�OF� 1-100
following reason.(Section 7031.5,Business and Professions Code:Any city or TQdE MET�i ORPOLEINST.
O� cauntywhkhrNulreaapem tWmtutruMt ier,impmve,demolbh,orrepalr / 1
Fq`'E�¢ ER
anystructere pdorto its Issuance,also requires theapplicant for such permute, _POWER DEVICES DAT- I` /
6� O file a signed statement that he b licensed pursuant to the provisions of the
3u, Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWDAMNG POOL EFCTRICVA TION
O sionI ofthe Buslne.and Professions Code)orthat he bxe
em themlmmand 1` }��
the basis for the alleged exemption. My violation of Section 70115 by any OUELETS-SWITCHES-FIXTURES !Qt —`v �a—W
applic t for a peroutxubjeet.the applicant too civil penalty of not more than
4 five ndrcd dMes,(ASo01. NEW RESIDENTIAL ELECTR
gggqgw I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTROCTION
GAG compensation,will do the work,and the structure Is not intended or offered for
O sale(Sec.7064,Bu boss and Professions Code:The Contractors License Law
3$ does not apply to an owner of property who builds or improves thereon,and OCC GROUT' RFS.UNITS o
EEE who docinuchwork himseBorthrough hisownemployees,provided that such rs -.�I
Improvements are not Intended oroffered for sale.Ifhowevepthebuildingor TOTAL: {�W
improvement lasold withinoneyearofmmpletiorythe owner-Wnderwill have
th,e,jarden of proving that he did not bund or Improve for purpose ofsae.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I_I 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors,to construct the project(Sec 7064,Business and Professions Code:
The Contnnor's License Law do.nota ly to an owner of property who
Wilds or Improves thaesry and w co races for such plojects with a ALTER-DRAIN&VENT-WATER(EA)
< actoKel Bansed unua
It.
.,it Hoc's Licence Law. BAIX FLOW PROTECTr. .DEVICE FEE SUMMARY
B&P C for this reOUTS]D11 ITES
Date _ DRAINS FLOOR RODE,AREA,COND. SANITARY RECEQefp
er WOR COMPENSATION DECLARATION SCIi/X)L TAX Y_ N_
[hereby offir at I have a artNcaee of consent to self-insure,ora F'lXTURES PER TRAP RECEIPT
rtl,L bC.Warkers'ComPa.ti.l..r m..A[fW.pytha.fBee. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab CJ RECETT N
Co GAS-GAS EA.SYS[GMOVER 4(EA) BUILDING DIVISION FEES
anCertl(ledy copy Vhereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLAN
MCertUed copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAI
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 2(X)FT. ?DEE
eeel t �J.Z
TThlssecRon need net W completed if the permit Ls forom hundred dollars
(9100)orI.JE RG N
I certifythat in the performanco ofthe work for which this permit is issued, WATER I-IEATERW/VENT/FIECTR —
I shall not employ any person In any manner so.to become subject to the WATER SY5I77.1/TREATING
Workers'Compensatlon Laws of California. Date PA Date R i t#
Z Applicant NEW RESIDENTIAL I'LMB. SOFT.
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Worker:Compensation proWiom of the Labor TO AL:
1- W Code,you mostforthwBh comply with such provisions or this permit shall be BU 1 Glctl
I-
> licensed revoked.
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE d
0. Thereby affirm that there b a construction lendingagency forthe perform TOTAL: ELECTRIC FEE
:) Z anceofthe work forwhichthb permit is hoseed(Sce.3097,Clv.C.) PLUMBING FEE
V0
Lenders Name
LL H Lneder's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U 1anilythat l have read thbappllcationaM state thattheabove information
0 W Iscorrect.I agreeto comply with all city and county ordinances and orate laws PERMITISSUANCE FEES PAID.
a relating to Wilding construction,and hereby authorlaa representatives ofthb —
Z city to enter upon the abovensentloned property( i pection purposes. ALTERORADDTOMECH.
_ Date Ree iptlt
(We)agree I., vl'
osave,indemnify an d keep ph
a the City of Cupertino AIR HANDLING UNIT(TO 10,000 CFM) $UBT AL:
V against liabilities,pdgments,costs and penes h hmayinanywayacaue
ag rst ultlC a ce of th gra nein o his pertni.
MR HANDLING uNIT(OVER lo,oa)CFM) CONSTRUCTION TA
as A&I fl Ig tureo ppBcant/Com ctor Date IXHAUS r HOOD(W/DUCT) CONSTRUCTION TA PAID:
HAZAR US AT necupa DISCLOSURE
illtheapplicaneor urcb dingompam score or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCC t#
crul as defined by the Irw Municipal Code,Chapter 9.12,and the
alth and SafetyCodeeSection 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOT
EJ Ye, , MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hagementa ab cordaminanb as defined by the Bay Area All
Q11lily Management l id,co BORER-COMP PFm OR 100,IXD BTU) I+'��
Yrs ❑No
ahaveread tcalth&Nous mode,Section requiunder rements aChapter 6.95 of BOILER-COMP(OVQ2100,000 BTU) 1 1991
theerstadteatif th&SafetyCode,Stcurr25505,ve a tandt,that 7 APR
understand that if the building don not currently haveatcnanL that ltbmy NEW RPSIDFNTTAL MECI-7. SQ.IT
re,poroibility to notify the occupant of the roqulrcerents which must be nae
prior to Issuance of a Certificate of Ocapancy. Cit ei rima.s i—I
(( t f, Ir a
Owner or authorized agent Date TOTAL: ISSIJEDB
OFFICE COPY