21349 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'et Identification 10 PER.WT NO.
Building Add rox.: s
'7s/6 21349
wnersme. -
A
'a CITY OF CUPERTINO-BUILDING DIVISION /d—I-/y [,v
cn a�tar/.q�{J Mc.No: APPLICATION / PERMIT
v ante: d BUILDINGELECTRICALPLUMBING-MMANICAL CATEGORY CONTROL a
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERWTISSUANCE- � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby Afbm that l am ecemed under prwWonsof Chapter 9(commenc APPLIANCFSRESIDENTIAL JOB DFSCRR'TTON
' Ingwith Section 7000)of Division3ofthe BuAruhsand ProfessionsCods,and my J �L7 �//,�//1/'�/In
license is inn Vjp cR aqd e.8 nG SSV, PANELS / A Pl`ye /1eol
License Lie.p tm a��� / ,
Date JaGJ-/ contractor 201-IOOOAMPS
ARCHITECTSDECLARATION OVER 1000 AMPS ' SQ.FT.FLOOR AREA 5/SQ.n.
9zI understand my plats shall be used es public records.
Fi Z Licensed Professional SIGNSELEC L s
<<�< OWNER-BUILDER DECLARATION SPECIAL CIR UI MISN
H, I I herebyaffirtn that l am exempt from the Contractor's License Law for the
OF O a following reason.(5c tion 7MIS,Business and Professions Code:Any dry or
7�H
county which requlrmaperrtJttomratmt,alter,Unpmve,demolbh,or repair TT]"P.M L INST.
'
655-1 any structure prior to Its Issuance,also requires the appBnnt for such permit to POWFRD 14E
o F V file a signed statement that he is Licensed pursuant to the proWioro of the
SWIhLMAtX0mow$ Contractor's Licnue Law(Chapter9(mmmencingwith Sedion7000)of Divi- WC
Won 3 ofthe Business and ProfessionsCode)orthat he Is exempt therefroma rad VALUATION
Yd the lush for the alleged exemption. Any violation of Section 7031.5 by any Q a
�<5 applicant fora permit subjects the applicant to a civil penalty of not man n O E SWITC Fl ES
c. five hundred dollars($500). NE ESIDENTf ELEC
.. Fj I,as owner of the property,or my employes with wages as their sok r'Q.PE STORIES . TYPE CONS'IRL'CTION
t- compensation,wBldothe work andthe structure b not intended or offered for
psole(Sec.7W4,BuWnass an l Professions Code The Contratoe.Lt..Law
�5$ does not apply to an owner of property who Wilda or improves thereon,and OCC.GROIR' HIS.UNITS
who does such work himself Orth rough his own employees,provided that such
Improvements arc not intended oroffered for sale.If,however,the Wilding or - L
,
Improvement issold within one year ofcomplellon,the owner-bullderwill have
tq,,p.,rden of proving that he did nor build or improve for purpose of sale.). QTY. PLUMB NGP RMIT FEE FLOOD ZONE APN
LJ L as her of the properly,am exclusively contracting with llmnsed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions,Code:
The Contractor's License law does nae apply to an owner of property who ALTER-DRAIN hVENT-WATER(EA)
Wild.or Improve.thereon, and who contracts for such projects with a
E, FEE pursuant m the Contractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I am exempt'under Sec. B k P C for this reason
OUTSIDE FEES
DRAINS FLOOR, A,ROOF,ARECOND. SANITARY Y_ N_
. Owner - Date ftECEB7R
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
1 hereby affirm that I have o momficiInsure tc of.cacticonsent elreythereo ora RECEIPT If
NfiLAI o(Worken'Compensatlonlnsurance m acertified copy thereof(Sec.
3800,LAIC) GAS EA.SYSTEM-t INGd OIIILEIS PARK FEE Y_ N_
P.B;;#: fell &223 - - RECEIPTN
Com env !��J a GAS EA.SYSTEM-OVER4(EA) HUI LDING DIVISI ON FE ES
erti0ed copy b hereby furnished. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertified copy I9 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCESEWER-SANRARY-STORM FA 2fX1F1' Date Receipt#
Crhiswdion need not be completed if the permit isfor ane hundred dollars
(51
(0)or less.) - WATER HFATIR W/VENT/Q.F-CTR ENERGY FEE Y_ N_
I certitythat In the performance of the work for which this permit is Issued,
1 shall not employ any person In any manner an a to become subject to the WATER SYSTEM/TREATING .
Workers'Compensation laws of California.Date - PAID
O Z ApplicantNEW RESIDENTIAL LMB. SQFT. Date Rcc i t#
Z O NOTICE TO MPLICANT:If,ofter making this Certificate of Exemption,you
should become subject to the Workers Compensation provisions.[the Labor TOTAL:
H N Cody you most forthwith comply with such provisions orthis permit shall be - BUILDING
CCj deemed revoked. -
LJ — CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
M I herebyaffirmthatthem Is a construction lending agency for the perforw TOTAL: ELECTRIC FEE
7 Z ane,of the work for which this permit is teaued(Sec.3097,Civ,CJ
V O Lender'.Name - PLUMBING FEE
LLF t<nders Addfem - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1mAlfythatl have read this applicationand gatethat the above information
4 is comet.I agree to comply with all ety and county ordinances and gate laws PERMI'TISSUANCE FEES PAID:
_ ,relating rebuilding ronsteution,and hereby authorize representativm of this
N cilytoenteruponthe above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify and keep harmless the city of Ce cAi.o -Date Receipt#
V a t liabilities,judgments,coxa and exp mwhkIt may Nanywayacuue AIR HANDLING UNIT CH)10,000 CFM) SUBTOTAL:
t said dty Inco cyue f thcgr ng of ehl.Permit.
{; �: f/I ATR HANDLING UNIT(OVFR 10,0-1-1CFM) CONSTRUCTION'TAX
Slkh/nattturee of AAplplilainntt/Conntrr/aa'ctorr- r Date 7 EXHAUsTHooD(W/DUCT) ,CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the I -
linalth and Sxfty Codm516,croftion 25S32(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes JL o
Will theappllmnto lure building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE,DATE
which e8 haamdom mminantsasdefined bythe Bay Arca Air
Quality Management DitOt7 BOILER-COMPPHPORI00,000BTU) - PA,D
4Yes No JU
have read theh materials requirements under Chapter 6.95 of BOEER-COMP(OVER 1WpW BN)ffie
Vndta�liforriallealth ndchatifthe Wilding dooes not avorrens ntly FaveSa tenant 3 and rtlutitlLv my " NEWRESIDENTIALMECJi. SQ.F 11ECj 1,tbilltytouxiytheomupant of he quirements which must be metissm cola fical{pfOc cy
/d
ner or authorecd agent Date - ISS r� a
TOTAL: — -
OFFICE COPY