21295 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Add mss: N 21295
060 IOW 6&S,D S
one: A A
r. �f„S h CITY OF CUPERTIN4BUILDING DIVISION /G^ ^�b
-11
c /:a � :7LIc. e: APPLICATION / PERMIT l
BUILDING-F3.EC'IRICALML BINGMECHAMCAL CATEGORY CONTROL N
A ect/Engineer. Lic.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions of Chapter9(rommmc- APPLIANCES RESIDENITAL q JOB DESCRIPTION
Ingwllh5 dion7000)of Division3ofthe Business salons Code,and my - \
limnse is in/tuufo d dfm. ^^01j,*
./� PANELS
License Cbm`^r QLIc.N .41j,
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
Z I understand my plans shall be used as public records. OVER I O00 AMPS \'9 SQ.FT FLOOR AREA S/SQ.Fr.
COC
b`j Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION S IAL CIItC T/MISC
Ihercby afRnn that Tam exempt fromthe Contractor.License Lawforthe
Z09 following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP MRTER OR POLE INST.
Qcountywhich mquimsa permittorommict,alter,improve,demolish,orrepair i pp ��}}
�� anystm=mpr toltstvsuance,alsom-quimtheappUontforsuch pemdt to \ POWER DEVICES Y .1 T
�i V file a signed statement that he is licensed pursuant to the provblom of the -
Ore Contractor's License law(Chapter 9(mmnNncing with Section 7000)of Divi- SWIM
OQ sion3of the Business and Professions Code)or that he is exempt therefromand 'V-qh'C POOL ELG C VALUATION
Q-tt the basis for the alleged exemption. Any violation of Section 7031.5 by any �Sr n.�ETS,SWf7C F[JCf1I
applicant fora permit subjMs theappliea tto.civil penalty d act more than '"t-� a v
pct five hundred dollars(5500). NEW RES[DEN'IIAI. RES
ELECTR�
�" I,as owner ofted '.QFr. STORIES TYPECONSTRUCTION
property,or my employees with wages as their sok
compensation,wlll dothe work and the structure Is not Intended or offered for
Osale(Sec.70K Business and Professions Code:The Contractors License Law
S does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UMTS
who dare such work himself or through his own employees,provided that such
Improvements arc net Intended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearofcompletlon,the owner-builder will have
tFtjZurden of proving that he did not build or improve for purpose of tale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE k-2—CV
to construct the project(Sec.70K Business and Profession Code:
The Contractors License law dam not apply to an owner of property who
\
builds or Improves thereon, and who contracts for such plojed.with a ALTER-DRAIN&VENT-WATER(EA)
�g0t�actor(9)licensed pursuant to the Contractor's Llmose Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
SIJ LJ I am exempt under Sec B& P C for this reason
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT N
WORKMES AN COMPENSATION DECLARATION FIXTURPER TRAP �� SCHOOL TAX Y_ N_
M,hereby affirm that I have a certificate of consent to self-Insure,or a RECERT N
certlflate of Workers Compensation Insurance ora cenifted ropythercof(See.
3800,lab C.) I S SYSTFM
GAEA. -]INC60UTLETS PARK FEE Y_ N
RECEIPT II
Palley N GAS EA.SYSTEM-OVER d(EA) BUILDING DIVISION FEES
Com any
�WC ed ropy is he d with he city CREASE/INDUSTR,WA57E INTERCEPTOR PLANCHECIC FEE
if ed ropy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Ihls section need not be completed if the permit Is for one hundred dollars
($100)orlev.) WATER HEATER W/VENT/FIECTR ENERGYPEE Y_ N_
1 mnily that In the performanceof the work for which this permit is Issued,
1 shall nm employ any person In any manner su as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California. Date PAID
O Z Applicant I
NEW RES]D[NT ALILMB. SQFT. Dale Remi t#
Z O NOTICE TO APPLICAN'T.If,after makl ng this Certificate of Exemption,you
should become subject to the Workers'Compematlon provbiom of the Labor TOTAL:
N Coda you must fort hwith comply with such pnevBiom or this permit shall be BUILDING FE
ccj deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Z is
Ihercffinrm
by anthat there is a construction kndingagency forthe perfoELECTRIC FEE
anon of the work for which this permit is wed(Sec.3097,Civ.CJ TOTAL:
02 I<ndera Name PLUMBING FEE
LL Iaeders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I cenifythat I have read this application and statethatthe above Information
O W is correct.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. IL relating to building construction,and hereby authorize representatives of this
in Z cit to entero the abwscnmr coned forty i ALTERORADDTOMFCH. Date ReeeiPt#
~ Y(We)agree oto save,Indemnify an d kkep property
the ity of cRu ppeertmo
V a ain't 11 Willies,pd mems,cons and expenses which may in anyway accrue AIR HANDLING UNIT DO MODEL CFM) SUBTOTAL:
lucid Cuy In aequeae of tls`granung rnhls permit CONSTRUCTION TAX
41W L4a
AIR HANDLING UNTT(OVER 10,000 CFM)
Igmt of Appllant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATCRI SDISCLOSURE
WI the applicant or future building occupant store or handle hazardous HPATINGUNIT(TO100,000BTU) Date Reeei 1#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
11n❑Yes MNo VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
11 the appikenlorfuture building.a deli .use equipmentor aevicts ir
which eManaement air ro'tamimmsas defined by the Bay Area Air
Quality Management DisWct7 BOILER-COMP OHP OR 100,000 BTU) /yA
1�1Yes -n No f
Ihavereadthehazar�O materials requirementsunderCh.frer6.95of BOILER-COMP(OVER100,000 BI U)
the California Iimlth&Safety Code,Sections 25505,25533 and 25536. I OCT p('�
understand that tithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.1-r G 1Jv®
responsibility to rally the occupant of the requirements which must be met J,7
prior ce ofa Certiflatc of Occupancy.
utPik
Owner or aulhorlsd agent Dale ISSUED BY:
TOTAL:
OFFICE COPY