21788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I'E7tMIT NO.
BuildingAddren: 21 O
,5-v0 12-1 ✓I rJ G Q
Phone: A A
-7, 9 -9 arm L CITY OF CUPERTINO-BUILDING DIVISION
1 Cormanor'sName: Lic.No. APPLICATION /PERMIT I�'�
P L 3 2 BU]LDINr—a. TRICALPLUMBING-Mr.0 AMCAL CATEGORY CONTROL N
ArchltM/Englruer. Lk.No:
Q7Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrnx PERMITISSUANCE �� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Hut lam licmsed under provisions o(Chapter9dr rni c API'LIANCESRESIDENTIAL JO DESCRETION
in tray I,ectlon 7W0)of Dlvislon3 ofthe Businnnand ProfnslonsCode,and my
limnse la in full form and dfM. PANELS .�^� � "..�
License C73�i1%t, t
Date 1 ConMaRor /'lff(,f wJN /��
ARCHITECTS DECLARATION a 201-1000 AMPS
q�+m7. (understand my plaa.hall be used as public records. OVER 1030 AMPS C '.i / Q. RAREA $/SQ.FT.
p;Q o Llmnseol I'rofevlonal SIGNS ELECTRICAL a Il gTEIR< OWNER-BNLDER DECLARATION SPGCWLCE4CUIT/M15C �
i., , Ihercbya(Brm tOWNE exempt ER the DECLARATION
Llrense law for the
following reason.(Section 7071.5,Buahmg and Professions Code:Any city or TEMP.METER OR POL INST.
KLE'� UAlt—
county which requires a permit to construct,alter,orprove,demolish,orrepair
d anystmmmpriortoitsL ame,aLsorequirmtheappBmntfww&pemdtto
V file a shed statement
that he is licensed pursuant to the provislom of the ]OWER DEVICES
Contractor's License law(Chapter 9(mmmencing with Section 7X(1)of Diel- SWIMMING POOL E.EC7MC
I0 skm3 ofthe Business and ProfesebroCode)orthat he is exempttherefromand ^1 VALUATION
St,
H Eb 3 the basis for the alleged exemption. Any violation of Stolon 7071.5 by any L4
O
ER applkantfor a perMtaubjMsthe applicant dv
anttoavll penalty of renot mothan OUf XTSSWITCHFS�FIXTURES
CID
five hundred dole.($SM. NEW RESIDENTIAL ELECTR SQFr.
A STOWFS TYPE CONSTRUCTION
6 c❑I,as owner of the property,or my employees with wages r thele sole
compensation,will doButtress
the work,and the structure T V not Wended or..L for
5�❑ rile(Sec.7044,Busbuss and Professions Code The Contractors Licensee law
$g does not apply to an owner of property who builds or improves therroq and OCC.GROUP RIS.UNITS
whodoennuchwork himself orthrough hlsown employees,provided thatsuch
improvements arc not Intended oroffered for vale.If,howevegtbebuliding or TOTAL:
improvementissoid within oneycarofcompletion,the owner-bullderwill have
t"Nen of provingthat he did not build rrbnprove forpurpoacofsale.). QTY, PWMBPERMIT FEE FLOOD IDNE APN
LI L as mune,of the property,am exclusively contracting with am.. PERMITISSXT10III
contractors to construct the project(Sec.704y Business and Professions Code:
The Cmucans 's Lim.law does sat apply to an owner of property who ALTER 1 WATER(EA)
Wilds or Improves thereon, and who contracts for such pkWD*ds with a FEE SUMMARY
<q➢t[adrn(a)licensed pursuant to the Contractor's License Law. BACK EVICE
LJ I am exempt under Sec B k P C for Una reason
DRAINS OUTSIDEFEES
F,ARG,CONT. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION *WRESSCHOOL TAX Y_ N_
❑I hereby affirm that I have a mrtNcats of consent to self-mmme,or
RECEIPT It
a REP. 'T
certificate ofWorkeri Compensation insurance ora malfied copythermf(Sec. GA EASTEM-1 CAO 5 PARK FEE Y N
3800,Ub )
Policy N_ C 5'9a 6s3 RECEIPT
Company Y/L'P�t y(L, GAS Yl'[iM-OR4(G BUILDING DIVISION FEES
CeniB copytsherebyfumished.
[�1Certified copy is filed with the city inspection division. CRGS IVDU A 1 FPTOR PLANCHECIC FEE
In+
CERTIFICATE OF EKEM PTION FROM WORK ERS' G PAID
COMPENSATION INSURANCE SEWER-SANRAR I G 200Ff Date Receipt#
(rhisaceikm need not be completed If the permit Is forms hundred dollar
(SIM)or less.) WATER FEATER W/Y ELFC g ENERGYFEE Y_ N_
I certify that in the performance of the work for which this permit is Issued,
I shall not employ any person In any manner an as to becorre subject to the WATER SYSITM/TREATING
Workcrs'Compensatlon lawn of California. Date PAID
Z Z NOTICETO APPLICANT:IL after making this Certificate of Exemption,you I NEW RESIDENTIAL PLMB. SQXT. Dale Remi tic
O should become subject to the Workers'Compensation provisions of the Labor TOTAL:
NCode,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
IL a CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL G Ihembyaffirmthat there is a mmtruction lendingagcnry,forthe perform- TOTAL: ELECTRIC FEE
Z arm of the work for which this permit is issued(See.3097,Cle.C.)
U �—
O Lender.Name PLUMBING FEE
U. I— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icer ify that l have read this applimtbn and state that the above Information
O W is correct.I agree to comply with all city and county ordinance and mate laws PERMIT ISSUANCE FEES PAID:
} 0. relating to building construction,and hereby authorire representatives of lhb
F N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? agree to save,Indemnify an d keep harmlev the C ty of Cu pertlno Date Reeeiptit
V agaWt labigika,jadgmenta, cad expect Eich ma syaccme AIR HANDLING IIMT(TO 10,000 CFM) SUBTOTAL:
agai said Citgln consegv fthe gee i ofthia itan
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
�a
EXHAUST HOOD Dais CONSTRUCTION TAX PAID:
HAl2ARDOUS MATERIALS DI 'LOSURE —
Willthe applicant or future building occupant ore or handle hanNots HEATING UNIT(TO 100,000 BTU) Date ReceI til
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yn UN.
Will the applicant or future building occupant FAN(SINGLE RFSID)pant use equipment or devices ISPWN#DATE
which emit hamnious air contaminants as defined by the Bay Area Air t
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) ( �(
4 Yee No jAg fv
have
ma
n
d the haca ous materials requirements under Chapter6.95 of BOILER-COMP(OVER 11i BN)
the California Health A Safety Code,Sections 25505,25533 and 25534.I
understand that lfthe building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECIL SQ.1-7 arm
responsibility to notify the occupant of the requirements which must be met s �c�
prior to issuance of a CertlOcate of Occupancy. ��
Owner or authorized TOTAL.:
agent Date ISSUED BY�L vl"'a�""'--�--a•
OFFICE COPY