21441APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
Building Address: -
ZI 8 v�
PERMIT NO.
21441
wners - one.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
UI
BLDING-FI,ECTRICAGPLUMBINGMECIIAMCAL
C=:c°nlractor'eName: LTc.No:
C E CO 2Z6
CA-� R
CONTROL #
Aahimet/Engine., LM. No:
•1 1, 11 "C PERMTT '„j+g); ' '
' ' i, -' BUILDING P.E,RMIT'INFO
Address:
'
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lcensed under provisions of Chapter 9(comment,
'ngwlth Section 7000).! DtV.i. 3ofthe Buatnesaand Pmfession.C.d., and my
license is In fullforceandeffect. /' /� !
License Claas��lic.# `t' 22_
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records'
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that l amexempt fromthe Contractor's License law for the
following reason. (Section 7031.5, Business and Prefeasions Code: Any city or
county which requires a permit to construct, alter, Improve, demolish, or repair
any structure prior to its issuance, also requires the applicant for such permit to
file a signed statement that be Is licensed pursuant to the provisions of the
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of Divi-
ivi-
sion
siion3of the Business and Professions Code) orthat he is exempt therefrom and
the bash for the alleged exemption. Any violation of Section 7WIS by any
applicant for a permit subjectsthe appllcantto a civil penalty of not room than
five hundred dollars ($500).
❑ I, as owner of the properly, or my employees with wages as their sole
compensation, will do the work and the structure is not intended or offered for
.In (Sec. 70K Business and Professions Code: The Contractoes License Law
does not apply to an owner of property who builds or Improves thereon, and
who doessuch work himself or through hisown employees, provided that such
improvements son not Intended oroffered forsale. If, however,thebuilding or
impementlssold withinoneyearofcompletioMtheowner-bullderwlllhave
th,e�+rden of proving that he did not build or Improve for purpose ofsale.).
IJ L as owner of the property, am exclusively contracting with licensed
contracims to construct the project (Sec. 7014, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such pikojecie with a
mAactor(s) licensed pursuant to the Contractor's License Law.-
LII am exempt under Sec. B & P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
.� `
1 '
Ex '• �,�
VVV LL` Y "1 V� 7
'
PANELS
701-IMOAMPS
OVER1000AMPS
SQ. FF. FLOOR AREA
$/SQ. FT,
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MLSC
7F.h1P METER ORIOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OON �•
D
OU7LETSSWITCHESFIXTURES
NEW RESIDENTIAL ELECTR SQ'Fr'
S
TYPE CONSTRUCTION
TOTAL:
QTY., . . PLUMBING PERMIT .'; FEE•'
PERMIT ISSUANCE
ALTER -DRAIN &VENT -WATER (EA)
C
RES. UNITS
FLOOGROUP
D ZONE
APN
BACK FLOW PROTECT. DEVICE
PEE, SUMMARY'.
DRAINS FLOOR, ROOF, AREA, COM).
FIXTURES PER TRAP
SAMTARY Y N—
RECEIPT N
Owner Dare
WORKMAN COMPENSATION DECLARATION'
[]I hereby affirm that I have a certlRcate of consent to self -Insure or
cerifimteofW.rken Compemationlr mncemacertifiedmpythereof(Sec.
3800, lab C.)
Policy p
SCHOOL TAX Y—N_
RECEIPT, p
GAS. EA. SYffi.EM-].INCA OUTLETS
pAXK FEE Y N
RECEIPT #
^y
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
CertlRed copy is hereby filed
❑Certified copy Is filed with the city Inspection division.
the city
•CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhiasess.) need not becompleted I(the permit V!coon. hundred dollars
(8100)°rly that o the person in ofthe
I ll not employ manner was to for cern eesubjecrmit is Ito theed,
I shag not employ any person in any runner ao m t° become subject to the
Workers' Compensation Laws o(GII(omla. Date
Applicant
Applicant
NOTICE TO APPLICANT: after making this Certificate of Exemption, you
should becocomesubjectto the
plywit Comp ensationprovisionsmthe Lab or
Cotler, you most forthwith comply with such provisions orlhls permitahali be
deemed revoked.
CONSTRUCTIONIsa;mm.LENOI en AGENCY
Iherebyaf(irmthat there lsacorastmctlon lending agency for the perform-
genc
once of the work far which this permit V Issued (Sec. 3097, Civ. C.)
.Lenders Name
Lenders Addreas-
I certdythatl have readthitapplicakmand Namthattheabove information
Escorrect.I agree to comply with all city and county onllnances and statelawa
relating to building constmction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities,judgments, costa and expenses which may in anywayaccrue
agalne it City in consequence ofthe granting of this permit.
�� /1 p��`
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID .
Date Remi t#
GREASE TRAP
SEWER -SANITARY -STORM EA 100F1,
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Recei t#
WATER M/TREATING
gYSTE
NEW RESIDENTIAL PENIS. SQ.Fr.
TOTAL:
BUILDING •'E
�[%�
TDTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERIv1IT �' 'i. EEE'
PLUMBING FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT( TO 10,000 CFM)
MECHANICAL FEE
FEESPAID:
Date RCCei [#
SUBTOTAL:
AIR HANDLING UNIT(OVER IQODO CFM)
CONSTRUCTION TAX
Signatu�fAppucant/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Rion 25532(a)2
F, Yea
Will the appEcant or tore building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
QualityManagement Drict7
4 Yes No'
have read the hoz on. materials requirements under Chapter 6.95 of
the Glifernia Health & Safety Code, Sections 25505, 25533 and 15534. I
understand that tithe building does not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
prior to]qu�eof��a Certificate
EXHAUST HOOD(W/DUCT)
CONSTRUCTION. TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Da[e ReCei t#
HEATING UNIT (OVER 1(8000 RTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
IS$UAI�ES�At+P
j*'E -
,44 n
' 4 1�4
�((y �/$„LL lft
G{i% V�t.
ISSUEDBY:
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEWRESIDENTIALMECH. SQ.FT
Owner or authorized agent Date
TOTAL:
OFFICE COPY