21283 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—' USE BALL POINT PEN ONLY
Building Project Identification _ PEILMITNO.
Building Address: - 212 8 3
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sera77
—Phone:
0 CITY OF CUPERTINO-BUILDING DIVISION
cnntrann• ! LIG No: APPLICATION I PERMIT
if • BUILDING-ELECTRICAL.-PLUMBING-MDCHAMCAL CATEGORY CONTROL X
- Archited/Engineer. LIc.No: ,.
rf FEE
'Q7 „•.," ,� ., bt.BUILD WC PERMIT INFO
�,ELECTRICPERM
Address: S� T -
rrxnHrlssuaNCE �' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION El
I Mrebyafn70t)ofUiv Bceme fun derinessaons'ffessio sC de,and APPLIANCFS.RESIDENTAti JOB DESCRIPTION
Ingwlth Sedion70W)o(d effect
ofthe Buslnesaand Pro(esslon,C'de,and my '
licensel.In fuV d h(' a•� PANELS
Liconse Cla Liep J VCZ
Date JI L.M actor aFJUP TO 200AMPS
ARCHITECTS DECLARATION 1201.10DO AMPS
reX I understand my plans shall Wound as publicmmrds. OVER1000AMPS - SQ.Fr.FLOOR AREA E/SQ.Fr.
O
q O
Q0 Licensed Professional SIGNS ELECTRICAL .
�6OWNER-BUILDER DECLARATION SPECIALCIRCU1T/MLSC
71„eYA?� -7 hercbya(firm that am exempt from the Contractor,License Law forthe _
FSQ following reason.(Section 70315,Business and Professions Code:Any dryer
I countywhich requires&permit to construct,alter,Improve,demoltsh,or repair TEMP.MEIER OR OLE INST.
�QQgg anyatm=mpdortolGt ance,aborequirestheappbantforwchperMtto
TMG y file a signed A muncnt that he Is licensed pursuant to the pm tsfi ,of-the POWER DEVICES
3w Contractor',License Law(Chapter9(commeneingwitbSectlon70C0)ofDivi-
�Og shm3oftheBusines&naProfessloesCode)arthat heisexemptthsrefromand SWP4MING POOL ELECT VALUATION
O the basis for the alleged exemption. Any violation of Section 70315 by any O[TI7.ETSSWITCHESFI ES 11 Q�' d
applicant fora permM it subject,the applicant to a civil penalty of nmore than
R flue hundredsowner ars of
p0). NEW Rgq EN77AL E(• STORIES TYPE CONSTRUCTION
..< I,as owner of the property,or my employees with wages r offered
sole fo
compensation,willdothe Business awork andions Code:
reh not Intended or'f. for
sale(Sec. pX6,Buaineeaandf property who
Wilds orContractorslmthatem law
does not apply to an owner of property who builds or Improve thereon,and
�$�^
who doesuch work himself or through hbown employees,provided that mch OCC.GROUIr RES.UNITS
Improvements are not Intended orofferedf'rsale.If,however,thebuilding or
have
iT TAL:
!-h
mprovemnntu,old wllhinoneyearo(complMion,theowner-bu0derwill
te I;orden of proving that he did not build orimprove for purposeofca�J. Q'[y, 1", PCUMBINC PERMIT' ? ,r FEE FT.000 TONE . APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMRISSUANCE
contractors to construct the project(Sec.7044,Business and Professions,Code:
The Contractor.Lt...law does not apply to an..or of property who ALTER-DRAINA VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pgojects with e
mpj{ad
m(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE '.,FEE SUMMARY"
LII am exempt under Sec. B k P C for this reason
DRAINS.FLOOR,ROO$AREASANITARYCOND. - SANITARY Y N_
Owner Date- RECPJPf=
WORKMAN COMPCNSATION DECLARATION IDC7lJRES I'ER TRAP SCI'IOOL T'AX Y N
hereby affirm that I have o Insurance
a c of consort m opytheure,ora RECh3PT X
certi0abofW'rken'Compematlon Wurana ora certllled copy thereof(See. GAS EA.SYSTEM-I INCA OUTLETS PARK FHE Y N
Polis lab CJ
P'llry Y GAS EA.SYSTEM-OVER A(EA) RECEIPT q
Com any B UILDING DI VISION FE ES
[EC[Cgytned copy is hereby furnished. GREASE/INDUsn$WASTE INTERCEPTOR PLANCI-JECK'FEE
erti0ed copy V filed withleththe cttyImpMlon divbi'n.
CERTIFICATE OF E)(EMPTION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE - SEWER-SANITARY-STORM EA.200FT. Date Re@I t#
(This sectl'n need nM be complded lithe permit La('Tone hundred dollars
($100)orless3 WATER HFATER W/VrNT/ELECTR ENERGY FEE Y N
I certify employ
the performance ofthe work for whichthis
e,permit I.Issued,
I shall not employ any person In any near n as to become subject to the WATER SYSTEM/TREATING
Workers'Compenaati'n laws of California.niDate .. - PAID
O Z Applicant
Z NOTICETO APPLICANT:It,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recel t#
O should become subject to the Workers'Compensation providom of the Labor TOTAL:
W Code,you=at fort hwlth comply with such provisions or this permit shal l b, BUILDING FEE
a
K fw
> deed revoked.
W
meG CONSTRUCTION LENDING AGENCY SEISMIC FEE
{hereby affirm that there Is a comtruction lending agency for the perform- ELECTRIC FEE
7 Z and'ftheworkforwhichthlspe,Mtbissued(Sec.3097,Clv.C.) TOTAL:
OQ Lender'.Name - PLUMBING FEE
LL X- lender§naamaa - QTY. - 'MECHANICAL'PERMIT FEE MECHANICAL FEE
OW :certify that i have read thisapplicationand statethatthe above information
IL Is cored.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID;
>. relating to building construction,and hereby authorize mpresentattvciof this
Zcity toenterupohe above-mentioned property for inspection purposes. ALTERORADDTOMWEL
— (We)agree save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
ago bwth.bl e,j'dgmenIs and expense whichemy In anywayaccrue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL'
&gal sal ity In con. s the anti thle permlL
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
ig rent Appllesnt/Contractor ./Dtf EXHAUST HOOD(W/DUCT)' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Will theappllontorfuty wilding ocdrpam store or handle havrdous HEATINGUMT(TO100,000BT11)
mDate RCCet f#
aterialzsdefined by theC rtino Municipal Code,Chapter 91Z and the -
IlealthandShcctyCodr 1'.25532(.)? HEATING UNIT(OVER 100,000 BM TOTAL:
0 Yes No
Will the applies nt orfutom building occupant use equiprmou or devices VENTI IATION RAN(SINGLE RESID) E91MANCE DATE
which eMt hazvdo"s ",r, Mnants as defined bythe Bay Are.Air •IppQ
Qu IRy Mamgement Dist 7 BOILER-COMP DI'EaDR 100,IXp BTU) OCT 2
M yes
N'
`T have read the hoz. ou onstsdalsrequirromets under Chapter 6.95 of 130ILER.COMP(OVI&2100,0000TU)
the California health k Safety Code,Sedl'ns 8505,25533 and 25536.I
and rouse its if"h building docs not avrrcntly have atenan4 that it ism NEW RESIDENTIAL M[CI7. SQ.IT.
responsibility edify the occvpa t of the requirements which most be met' lf1�T, i'�,/ •SFA
prior I.IJ ce ofd CrAiflate O ry,
��� Mal
authorized agent! Date
TOTAL:
OFFICE COPY