21342 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idendfiaalon PER.wT NO.
Building Address: 21342
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a ,.. arae:
rse�D 5---7-ane CITY OF CUPERTINO-BUILDINGDIVISION A >�
Cnnty�:,Name: Lic.No: APPLICATION / PERMIT
i�O BUILDING-FL C RICALPLUMBING-MECHANICAL CATEGORY CONTROL 4
Architect/Engineer. Lk.No:
,QTY ELECTRICIPE_RMTT FEE BUILDING PERMIT INFO--�;�- :
Address: PERMITISSUANCE O ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ih<rcby affirm that lam licensed under provisions ofClupter9(mmmmc APPLIANCES-RESIDENTIAL JOB DFSCRTIPIION
ingwith Setlon70W)of Division3ofthe Buslnessmd Pm(essionsCode,and my ��•a
license is In lul dd(et. PANELS / a -y�
Llcenu Coss Lich �/GS� A
Date Contractor —„qer//T-�"/ "•
ARCHITECTS DECLARATION 201-IM AMPS
ce I understand my plans shall be used as public records OVER 1000 ANTI'S SQ.FT.FL R AREA $/`.Q.FT.
x fjO SIGNS ELECTRICAL
(Cj Licensed Pin mactmol _
i OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
1hereby.ffiren that lam exempt from the Contractor.License Law for the
7 9 :- following reason.(Section 70315,Business and Pmfessiom Code:Any my or TEMP.METER OR POLE INST.
zy cwntywhichrequl apermittomvt c"ter.4 pmw demolbh,orrepalr
11 .mss anymm=mprlortoibi ancgalsorequimtheappn=tforsud per tto POWER DEVICES
S C
U file a signed statement thrt he Is licensed pursuant to the provisions of the
O' Comrsct.e.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
VALUATION
fig basis
fo the
Profemion. Any)arthrtheb exempt therefrom and ss
Pry,' the baab for the alleged exemption. Any t tolacon o(Sa tion Iloilo by any OUiLETSSNgiCHFSpUlT1RF5 cm� applicant permit subjectstheappOcanttoa civil pessary dna room than——
five hundred dollars(A50o1. NEWRESIDENTIALELFCIR SQ STORIES TYPECONSIRUCTION
I,as owner o(the property,or my employers with wages as their sole
compenvtlon,wllldothework and the structure b tort Intended or offered for
O
sale(Sec.70K Business and Pmfesdons Code:The Conmactoes License Taw
r$ does not apply to an owner of property who builds or improves thereon,and OCC.GROU? RES.UNITS
.- whodoessuchworkhlmseUorthrough hisownemployees,provided that such
Improvements are not intended arof(emd for sale.If,however,thebuliding or TOT
improvement bsokl wlthnomyearofcompleion,theowner-builderwgl have
trden
tlof prmmgthst he did tart build or improve for purpaneof We.). QTY: - PLUMBING PERMIT _ FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PQLMR ISSUANCE
contmeturs to combuct the project(See 70K Business and Profevbv Code:
The Contractor's License Taw does na apply to m owner of Pmpety who ��-DRAIN 6 VENT-WATER MM
Wild. or lmprwes thueon, and wham tracts for such piojects with a _ _,'FEE SUMMARY,
gIltIactor(s)Bcensed Pursuant to the Ca Ree'ILicenx Law. RAIX FLOW PROTECT.DEVICEOUTSIDE �• ^I �T
LFEES
J I am maunder B I P C for this reason
DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y N_
Ow — RECEIPT Y
I -WORKMAN COMPENSATION DECLrCAATION FDnIfRES PER TRAP 5Qi00L TA% Y_ N
I hereby af(Irm that I have a certificate of consent to self-Insure,or a RECEIPT N
zoo,
of Worker,Compensation insurance ora ratified copythermf(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
W,Wb C.) "iC /�7yQ� RECEIPT
Policy. IN C GAS F.A.SYSTEM-OVER 4(EA) BUILDING DIVISIONFEES
Com ani
[�Cetmed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
91CetiBed copy b filed with the city inspection division.
CERTIFICATE OF OEMPFION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.XpF T. Date Recd tq
(Thissetion need nest be completed if the perrnt[is forms hundred dollars
($IW)or less.) WATERHFATERW/VENT/ELFCTR E'NERGYFEE Y_ N_
I certify that In the performance of the work forwhich this permit is blued,
1.hall not employ any person In any manner ro as to become subject to the NATER SYSIEM/TREATING PAID
Workers Compensation Laws of California. Data
C' Z Applicant NEW READENITAL PLMD. SQFT. Date Recef 0
Z O NOTICE TO APPLICANT:11,after melding this Certificate of Exemption,you
should become subject to the Worker'Compensation provisions of the LaborCC TOTAL:
— n Code,you wast forthwith comply with such provisions orthb permit shall be BUILDING FEE
j deemed revoked.
(L — CONSTRUCTION L04DING AGENCY SEISMIC FEE a
Q. I hereby affirthat there b a construction lendingagency,forthe petonn TOTAL; ELECTRIC FEE
m
M Z once ofthe work for which this permit bbued(Sce.3097,CIv.C7 PLUMBING FEE
C.) O lendds Name
h- nders Address QTY. MECHANICAL PERMIT „ FEE''
LL Le
MECHANICAL FEE
In Icenlfylhatl haveraadthb.ppllvtonaod statethatheabwelnfamudon FEES PAID
O
b correct.I agree,to comply with all city and county ordinances and tate law. PERMIT ISSUANCE
} IL relating to building coamclim,and hereby authorize repmentative.of this DD'R7 MECH.
.F W city to enter upon the above-nantloned paperinspection forinspectionALTER ORA
ion purposes. Date Recei Hl
*(MWVcgree to save,Indemnify d p harmless the City of Cupertinob111t ,jsdgrrcnn,costsand s which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Id C' imm. bill trsnng Mthispennit. AIR HANDLING UNIT 10,"CFM) CONSTRUCTION TAX
A
CONSTRUCTION TAX PAID:
Sig awreof Applicant/Contractor Date IXHAUST HOOD(\V/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000BNJ
Will the applicant or future building oaupant store or handle harardoos Date Recej tN
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Fleakh and Safety Codon 75533(a)i HEATING UNIT(OVER IKOW BTUs TOTAL:
F1 Yes No VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
Willthe applicant oir future building occupant use equipment or devices
which emit h.rardousav
contamints as defined by the Bay Area Air
Quality Man.geme It D'u 97 BOILER-COMP(3FI'ORl00,IX1)BTU) PAID
Yes o
l.vrmad the materblsme irement under Chapter 6.95 of BOILER
-COMP(OVp�i 100,00()BTU) OCT
the Call(ornl.Elealth Safety Calq Sectio 505,75537 and 25534. I VC I z Ei 1990
unit rsndthatif the building doe.not m`mhhave a tenant,that It b my NEW RESIDENTIAL MECI i. SQ.FT.
o ability to nalfy e p tof th m.which must be met
p ceu ce ofa 't t fOcm City of /;IITIPrf14B1
C7 nerorauthmired a gent Date TOTAL: ISSUEDBY:_ ✓�•
OFFICE COPY