21567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmj rt Identification 7 PERMIT NO.
Banding Add.,,:
^` � b i noel W A 21567
'nvner ams: one: A
PArTFI E 4srMla K-) '/] — Q CITY OF CUPERTINO-BUILDING DIVISION q
C [�I :MQSM O APPLICATION / PERMIT�3� Z
Architect/Engineer. Llc.No: BULDING-ELFCTRICA4PUMBING-MSCINlcAL CATFCARY — CONTROL
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSBD CONTRACTOR'S DECLARATION
[hereby affirm that l am licensed under pro uslons or Chapter9(mmmenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth5 i.t 70M)of Dlvlelon3ofthe Bu,in and Profs ma Code,andmy
liconee la In(u o . d PANELS
LIce�sQC6ss 1�LIc.N Sf�N__�p-�)- _ ��a
Dat ll ContraRor II['.(�Q_/-1 rI•I 201-IMOAMPS Y3
ARCHITECT'S DECLARATION J
07 [understand my pore shall be used.public cameos. OVER1000AMP5 SQ.Fp.E7.ODR AAFA f/SQ.FT.
O
Licensed Professional - SIGNS ELECTRICAL
I
OWNER-BUILDER DECLARATION n a SP[CL1L CItCU1T/MISC
owing rayon. that Clamexemptfromthe Contractor'sLicense.luno Law Aryciethe
pcountywreason.requiSection7031,5,Buatnem and Professions Code;Any ctepir
F Z F.� TEMP.METER OR POLE[NST.
county to
permittomm requires th aprovgderrolbh,or repair
q' anya signed statement
its that
he is aLw requires pursuant to the provisions
ofpermit e POWER DEVICES
f5 Ifs a actor.statement that het rimmed pursuant it the Pon 7000) of the
Ow ivi-
gun 3 of the
Limesse and PChapter9(comnondat he In exempt
)of and SWIMMING POOL ELECTRIC VALUATION 'f
mon3ofthe Bumneeedexemption.Anyviethrtheti exempt therefrom and 04
y�< the bean for the alleged exemption. Any violation.f Section 7031.5 by any OUl1,E.IS5V.7.I'CHFSPI%7URFS h O 1
appp rive hundred fora pems(S50it 0rds the applicant toe dull penalty of no more than l
a five 11,as oddollarshepro
NEW RESIDENTIAL ELECTR SQ.FT.
(d••�n ❑e as owner of the property,or he employees with wages as thele sole STORIES TYIPE CONSTRUCTION
cold mpensation,wusdess andothe rk,andlhes Code;
durehe is Contractorot orcenseLaw
d for
q eomnot.7Wy to an
Professore Co Wilds Contractors thereon Law
$� does not apply to en owner of property who bulWs orlmprovea thereon and - l3CC.GROUp RES.UNITS
whodoessuchworkhim lforthr.ughhisownemployees,providedthatmch
Improvemenb are not Intended oroffered for sale.If,however,thebullding or TOTAL:
improvement haold within oneyearefcompletloR the owner-budderwill have
t}kjxuden of proving that M did not build or Improve for purpose of sale.). OTy, ,s•-.PLUMBING PERMIT .FEE b7-pOD[ANE APN
Lf I,as owner of the properly,am exclusively contracting wish Ilmnsed PERMITISSUANCE
contract..to coretr.ct the projed(Sec.70K Business and Professlmu Code:
The Contractors License Law does not apply to an owner M property who ALTER-DRAIN la VENT-WATER(E13)
W Ids or Improves therem,and who contracts for such ptojem with a
ctor(s)hceneed pursuant to the Contractor'+License Law. FEE SUMMARY
am exempt under Sec. B k PIfC for thinrcawn BACK FLOW PROTECT.DEVICE
• Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N—
WORKMAN COMPENSATION DECLARATION RECEIPT N
01 hereby affirm that I have a certlBcate of consent to self-Insure,or FDCNRES PER ISP SQi00L TAX Y N
certificate o(Wori,enaCompersation Insurance ora certlfle i copy thereof(Sec. RECEIPT 0
3800,Lab C. py GAS EA.SYSTEM-1 INCAOUTLEI'S PARK FEE Y N
PWI RECEIPT N
Com n, 7i4 U S A)GAEA.SYSTEM-OVER BUILDING DI VISION FEES
Lj Cimi(ied copy Is hercbyth the city CREASE/1NDUSD(L WARM INTERCEPTOR PLANCI-IECKFL'E
❑CerliBed copy V filed with the city W)sedlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAM•I.ARY-STORM FA.20OFT Date Recei tN
00)
(0or I ion need rad be complded if the permit V(or one hundred dollars
($100)or WATER HEATER W/VENT/ELFjCTR ENERGYFEE Y N
Icertlly that performance pertoano(the w.rk(or which this permit is , —
I shall not employ any per..In any manner se as to become subject to the WATERSYSTEM/TRFATING
W.rkeri Comen
psation Laweof Califomia, Data PAID
—
Z Z ApplicantNEWRFSIDENTIAL PLM B, SQ.FT, Date Recei t#
Z O NOTICE TO APPLICANT;[,after making this Certificate of Exemption,you
should become subject to the Workeri Compereatlon provisions of the Labor TOTAL:
W Code,you=at forthwith comply with such provisions orthis permit shall be d
> deemed revoked. BUIL 'E . J
W
GCONSTRUCTION LENDING AGENCY SEISMIC FEE s
. I hereby affirm that there i,a construction lending agency for the perform- ELECTRIC FEE
M Z ance of the workfor which thin permit V Issued(Sec.3097,Civ.C.) TOTAI.:
U O [ender.Nana PLUMBING FEE
IL h— Ismer,Adore„ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cerlifythatl have madthia applieatlonand mamthatthe above Information
(1 iscorrcd,I agree to comply with all city mut county ordlnanms and mate laws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and hereby autor
h@.representatives of this
Z city to enter upon the above-mentioned property for inspection purpose, ALTER OR ADDMMECH.
(We)agree to save,Indemnify as d keep harmless the City of Cupertino Date Receipt#
V
ails[net liabilities,judgmcoents, ailed expenses which may in any wayaccrue AIR HANDLING UNIT(TO 1 8000 CFM) SUBTOTAL:
against said CltL'L cones ace f the granting of this pe It.
Sign r �Cy �Xw AIR HANDLING UNIT(OVER I0,000CEM) CONSTRUCTION TAX
Signature of Applicant/Contractor +3 Data
EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCL URE
Wllithrappll or future building occupant store or hand le hanrd.us HEATING UNIT(TO 100,000 BTU) Date RCCCI I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - _
Health and SafetyCode Section25532(a)? I(EATING UNIT(OVER 100,000 BTU) TOTAL:'
❑ Yes M No
Wllltheappliant orfutumbuildlogoccupantuseequipra rat ordevices V1=1ATION PAN(SINGLE RESID) GihhICE DATE
which emit hazardous air contamirunte as defined by the gay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
PYesn❑No
h read the bazar zeaterials requirements under Chapter 6.95 of BOfLFR.COMP(OVER I00,ODO gni) U�4 4199Q
the California Health A Safety Code,Sections 25505,25533 and 75536. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDEMTAL MECH, SQ.hT. '
mapoegbifity,to nalfy the occupant of the requirements which must be root /11�y asi Ia..sa�j�
poor to issuance of a Certificate of Occupancy. N1► Vl YY`161 u
Owner or authorized agent Data ISSUED BY:f
TOTAL:
OFFICE COPY