21693APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hu lid in Pro'crt Idemifkatlon
Building Address: ry s�W-I�,� -
'-t
PEthllT NO.
21693
re me:
1
w�TA C.�Y S arse
CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING-MECHAMCAL
�^�,�
Contra raName: Lie. No:
S I 3'
CATFfARY
CO NTROLp
Art Itect/Engineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
y�y�I�
i Y�
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions c(Chapter 9 (Commenc
Ingwith Scction7000)of DXvision3ofthe Businemand Pmfma ms Code,and my
ceras - ss C. �
license In full o MCI Contra---- �
Date Contractor
RCHITECTS RATIONP
I understand my pians shall be used a public records.
Licensed Prof Ciatoml
OWNER -BUILDER DECLARATION
I hereby affirm that I am m
exempt frothe Contractor's License taw for the
following reason. (Section 7¢315, Business and Profeulons Code: Any city or
county which requires permit to Construct, alter, improve, demollsh, or repair
any structure prior in, its Issuance, also requires the applicant for such permit to
file a signed antement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of DWk
ston3 ofthe Bueineu and ProfessionsCode)orthat hats exempttherefromandS,
the bast+ for the alleged i xemptlon. Any violation of Section 703IS by any
rr
applicant fora permit subjects the applicant to a civil penalty of not orethen
live hundreddollarsof the property,
❑I,as owner theproperty,or my employees with wages as their sole
compensation, will do the Business awork and toes Code: Th not intended or cense L w
Ole (Sec. apply to an ow and Professions Code lids Compactness thereon law
.h.d.does tapply rkhinerorth propertywho
empl)Tcs,pmidelids or impoorvess reon,and
whodoementsworkhimseldedm ugh hbowudc.If th. dihatsucr
Improvement arcnot hindneyearfe mpleto.thehowever, niider ilI have
Improvement lseold withinoneyearoncompletlon.theowner-bullderwlll have
thp�iurden of proving that he did not Wild or Improve for purpose of ukJ.
LJ I, as owner of the property, am exclusively Contracting with licensed
Contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contractor's License law does not apply to an owner of property who
builds dor Improves thereoE
n, and who contracts for such xujMs with a
cgDlfactnr(.)licensed Pursuant to the Contractor's License Law.
L5 I am exempt under Sec. B & P C for this reason
APPLIANCES RESIDENTIAL
JOB DESCRIPTION
UP ELS
TO 200
201-1000AMPS
OVER 1000 AMPS
SQ, FT. FLOOR AREA
$M. FT.
( SIGNS ELECTRICAL C
SIPECIALCItCU[T/MLSC
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING TOOL ELECTRIC
OII7LETSSWILCHESHXTIJRES
.g0at V,A�L,U1A'ETON
`"{, � 0 x �L
NEW RESIDENTIAL ELECTR SQ}7
TYPECONSTRUCTION
sr
TOTA;
QTY, PLUMBING PERMIT FEE
.GROIJIP
RFS. UNTTS
ppgMIT LSSUANCE
ALTER -DRAIN &VENT- WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE VES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT N
Owner Date
WORIONAN COMPENSATION DECLARATION
1-11 hereby affirm that I have a certificate of consent to sel6lnsure, ora
Certificate o(Workeri Comperwtlonlosurance or a certified! coPythC..f(Sec.
3800,
3800, Iab C.)
icy N
H%'IVRFS PER TRAP
SCI100L TAX Y N
RFLFII'T N
GAS PA INCA OUTLETS
PARKFEE Y N
RECEIPT p
GAS EA. SY517Id-OVER 4 (G)
y
BUILDING DIVISION FEES
Cenlfted Copy t herebyth the city
�Cenilled ropyt(Iled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(This section need oat be completed If tM permit t (Drone hundred dollars
(f100)orlesa0
I cenoy that In any peoron In an tmanner sorwMch his ccong permit b to ed,the
I ore not employ any person In any manner an u to become subject to the
Workerv'Compendotlon Laws of California. Date
Applicant
NOTICE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become aubRd to the Workers' Campensatlon proWloru of the Labor
Code, you must forthwith Comply withsuch provisions orthis permit shall be
deemed reVOked.
CONSTRUCTION LENDING AGENCY
I hemby affinnthat there is a construction lending agency for the perfanm
ance of the work for which this permit t Issued (Sec. 3097, Civ. C.)
I<ndeh Name
Isnder'a Address
I ceditythat I have read this apphationand natethat theabove information
Iscorrect l agmeto complywlth all city and County ordinances and state laws
relating to building Construction, and hereby authorize representatives of this
city to enter u port the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu Fenlon
agaWHlabilities, P rig ts, costsand expenseswhich may In any wayaccrue
ago oat cold City in con doe fthe grantln this permlL
Z 2 Zl
m Applin / o tr cto -/�Qa
N RDOUS MA OS Rfl�'1
Will the applicant or future bull Ii g occupant store or handle hazardous
murriai as defined by the Cupertino Municipal Code, Chapter 9,12, and the
licalthand SafetyCode Sectlun25532(a)?
❑ Yes No
Will lheappliant or turn building occupant use equipment ordevices
which emit haeardous air Contaminants as defined by the gay Area Air
Quality Management District?
4 raid Yes gNo
have the baso nus materials requirements under Chapter 6.95 of
the Celifnmia Health&Safety Code,Sections25505,25533and255M. I
understand that lithe building does not currently have a tenant, that It Is my
pdor to issuance of a y the occupant
p6or tolls ua to notify the occupant of the requirements which most be met
of Onvparacy.
GREASE/INOUSIRL WASTE INTERCEPTOR
PLANCI-IECKFAj `
;z-,,
PAID"
Date R t#
^� �1�
L43b
GREASE TRAP
SEVVER-SANITARY-STORM 2OOFT
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y —
PAI
N
WATER SYSTEM/TRGTTNG
NEW RESIDENTIAL PLMB. SQ.FT.
a CCCI [
OTAL:
L E
SEIS C FEELID
- TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMTTLSSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date RecCi [
P
AIR HANDLING UNIT CID I0,000CFM)
SUBTOT L:
AIRHANDLING UNIT(OVER I0,000CFM)
IXHAUSTHOOD(W/DUCT)
:CONTR2U7ONX
PAID:
HEATING UNIT (TO 100,000 BTU)
CCC [N
HEATING UNIT (OVER 100,000 BTU)
OT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
ay S
E'R�l
r �9
ISSUEDB
BOILER -COMP DEEP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
Owner or authnrlud agent Data
TOTAL:
OFFICE COPY