21471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
building Ponied Identification PERMIT NO.
BuildingAddress: 21471
�-
wnra one: p A
_ CITY OF CUPERTINOBUILDING DIVISION
tractor's Nairc: Lie.No: APPLICATION /PERMIT
BUILDING-D.ECTRICALnL SING.MFO MCAL CATEGORY CONTROL N
Architect/Fegineer. Lk,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE JZQ
LICENSED CONTRACTOR'S DECLARATION �T
I hereby affirenthat
lambomedunderpervislonof Ch.ptcr9(.emm. APPLIANCESRESIDENTIAL �JOB DF£CR(sIeIII�O
N
InSectbn fDlvtheBusineaand arofesslonaCode,and my
license Ib fun force ond effect.
PANELS
License Class -Lk.N
Date Contractor UP TO2DO
ARCHITECT'S DECLARATION
oZ I understand my plans shall be used as public records, OVERIODOAMPS SQ.Fr.FLOOR AREA S/SQ,FT.
COC
19 U Llrensed Professional SIGNSELECTRICA
�
<y OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ /
to 'o Lherebyaffirenthailamexempt fromthe Contractor's License lawforthe f/
7.9 following reason.(Section 70)1.5,Business and Professions Code:Any city or TEMP M OR PO INST. Ph
04f"B countywhkh rqulres a permit to romtruct,alter,Improve,demolish,oreepalr
�.a any structure prior to its Issuance,aLso requires the applicant for such permit to IOWF.RD I
file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License (ChapterLaw 9(commencin ithSection 7000)ofDivi.
VALUATION
�OO�' Yon3ofthe Business and ProfeaioCode)orthatt he b exempitherefromand SWIdMINC L CTRL 3S [ ^
O the basis for the alleged exemption. Any violation of Section 70)1.5 by any O ETS FI E5 `J CTU
1—V
666
applicant for a permit subjects the applicant to a civil perultydmre
nat othan
�$ five undyed dollars(SM. NE RFS AL L SR.FI. STORIES TYPECONSTRUCTION
j.. 0,as owner of the property,or my employees with wages as their sole
7Q compensation,wllldothework andthestructurohnot Intended or offered for
0 sale(Scc.7044,Business and Prdesalomu Code:The Corda"ora License law
does not apply to an owner of property who builds orimproves thereon,and OCC.GROUP RFS.UNITS
0. whodoessuchworkMmseiforthrough Msown employees,provided thatsuch
improvements are not Intended oroffered fersak.If,however,thebullding or TOTAL:
Improvement bsold within one yearof completion,the owner-W Bderwil have
taen of proving that he did net build or improve for purpose ofsak.). QTY, PL PE MIT FEE FLOOD ZONE APN
z as owner of the property,am exclusively contracting with licensed PERMIT!! E 1
contractors to construct the project(Sec.7094.Business and Pmdealoa Code: l
The Contractor's License Law does not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such projects with a
��/�a�ctorls)fixa sed pursuant tothe Cotra .License Law. FEE SUMMARY
A am a empt undo Sec zQ • B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE
I SANITARY Y_ N_
DRAINS FLOOR ROOF,ARCA,GOND.
Owner N, a Date RFOFRPTX
WOR KM CO661PENSATION DECLA TI N FI%T[RLES PER TRAP SCIBOOL TAX Y N
❑1 by affirm that I have a com0ate of consent to selLinsure,ora RECEIPT N
certlnate of Worken'Compeaatlonlnsurance ora rerti(Ied copythemo((Se<. GAS EA.SYSTEM-1 WCAOUTLEIS PARK FEE Y N
3g00,1.ab C.) RFOFTPTN
Policy X GAS EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
Com any
�Certlfled copy is hereby furnished. GREASE/INDUSCRL WASTE INTERCEPTOR PLANCFIECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF Ei(EM ITION FROM WORK ER S' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANTIARY-STORM EA.MIT. Date RCCCI t#
(This section need not be completed If the permit Is for ore hundred delta.
(a100)m leas) WATER HEATER W/VENT/FI-ECTR ENERGY FEE Y_ N_
I cortlfy that In the performance of the work forwhlch this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
WinlIes Compensation Laws of California.Date PAID _
OZ Applicant NEW RESIDENTIAL['LMB. SQFT. Date Recej t#
Z O NOTICETO APPLICANT:If,after raking this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
F W Code,you must forthwith comply with such provisions or this permit shall be BUILDING "E
W j deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE 5�
M ° Iherebyafflrmthat there is a construction lendingagency forthe perform TOTAL ELECTRICFEE
Z ance of the work for which this permit is maed(Sc.3097,Civ.C.) PLUM
EE
() O lenders Name
Aw
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHAN
OW Iecrtifythat l have read thisappIlationand Yate thattheabove information
a bcorrect.I agree to comply with all cityand county entrances and Yate laws PERMITISSUANCE FEES PAI
relating to W llding romtructlon,and hereby authortne mpresentatives of this
N city to enter upon the abovcmentioned property for lespecllonpurposes. ALTER OR ADD TO MECH.
_ Z Date Receipt#
(We)agree m save,indemnify an d keep harmless the City y Cupertino AIR HANDLING UNIT(TO 10,000 CFM)
V agaWtllabilltla,pdgmenb,coYsand expense which may In anywayacaue SUBTOTAL:
against Id Cityinm a (t granting dthla pe
AIR HANDLING UNIT(OVER 10,070 CFM) CONSTRUCTION TAX
Slg mof Appllan�oe / Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardous BEATING UMT(TO 100,000 BTU) Date Recd t#
material as defined by ted Cupertino Municipal Code,Chapter 9.1Z and the
rlalth and Safety Cade Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUARAWTE
which emit hazardous air centandants as defined by the Bay Area Air
Q",xl'tY'rea Management District? 1�BOILER-CAMP OFI'OR 100,Of108TU) ^,0Y!lIMMM V 1 0a
ThavereadlhehanjrtmmsratedalsrequlmmenhunderChapter6.95of BOILER-COMP(OVER1W,000BTU) o
the California Health&Safety Code,Sections 25505,75533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT Pais.
resss�V/1,
pondbllitytonaifytheoccupantoftherequi,me.tswhichmustbereal �`� w1 upedino
prior io Lssuance of a CcAificate of Occupancy.
Owner or authorized agent Date ISSl1ED BY k
TOTAL:
OFFICE COPY