21340 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Add.a.; 21340
opo s 81 d�, 5�,,�
ware came: n ne:
_ CITY OF CUPERTINOBUILDINGDIVISION
C/p`n A'score Name: ^.� C uc.N APPLICATION I PERMIT Y
L�C�m ��• 3R5-7�!i BUfLDINCELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL a
Llc.N �1�
��/ AmAlt /Engineer. a L
QTY " ELECTRIC PERMIT" FEE ', BUILD NG PERMIT INFO
Address: I PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby
i.flrm'hat lamllcerxM under viand Pm Chapter ,.ca enc APPLIANCFSREADEhTIAL JO DESCRIPTION
ingwbh toW1171K0)anDivfect. fthe Budnessand Pralesslonm(ade,and my
license Is in ful and affect. PANELS
LlrenseChssLic.N ` �aCT♦ 7Date Contractor
ARCHITECTS DEC RATION 201-1000 AMPS
regC ]understand myplansshallbeumed aspublicreccards. OVERIDDOAMPS SQ.IT.FLOOR AREA $/SQ.FI.
05
U Licensed Professional SIGNS ELECTRICAL ,9r
Q OWNER-BUILDER DECLARATION /l,, SPECIAL CIRCUIT/MISC .cp
7F ,/a I herebyaftlrmthat l am exempt from the Contractor's License Law for the `0 t
pp following reason.Gddioa 7¢11.5,Business and Professions Code:An cit or
Fq county which requlrcsa pernuttomestruct,aIle,improve,demolish,orrepair TEMP.ML+TIR OR POLE INST.
'� .❑7 anystructure pdortoitsiesuance,also requlmthe applicant for such permit to
O file a signed statement that he isBernard pursuant to the provisions of the POWER DEVICES
Contractor's License Lav,(Cha er9(commencin io
withSectn7000 .(DIW-
SOS sion3 ofthe Business and Profeml.ns Code)orthatt he is exempt therefrom and SWPIA9NC IDOL ELECTRIC VALUATION
�^ the basis for the alleged exemption. Any violation of Section 7031S by an
<S
applicant for mit subjects theapplicant to a civil It of not more than OUTLEISSW[TC \FIXTURES
O�J PP per Mpenalty
fi Eve f,as o nerdolof the pr. NEW RESIDENTIAL ECTR SQ FT STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as theirsole
compensation,will do the work and the structure isnot Intended or offered for
O
In&c.70K Buatmeas a nd Professions Code:The Contractors License Lw
j3$ does not apply to an owner of property who builds or Improves thereon,and
OCC,GROIII' RES UNEfS
EE who does much work himself or through him own employees,provided that much
Improvements am not Intended orof(ered lorsale.If,however the building or TOTAL: �®
improvement issold within one yea rofcomplation,the owner-bullderwlll have
tte�urden of proving that he did not build or improve for purpose ofmle.). QTy, P PERMIT FEE' plpoDp NE APN
u I,as owner of the property,am exclusively contracting with licensed AN
contractors to construct the pmject(Sec.7064,Business and Professions Code:
21®
The Contractors Licence law does not apply to an owner of property who RAIN\"-WATER(EA)
Wild. or imp..theon,and who contracts fns such p(ojeae with a yry
cgRS��ctmexe pt under antSm Rothe Contractor's License Law. P TEC .DEVIC FEE
OUSUMMARY
EFEES
U I am exempt under Sec B k P C for this rcuon
Owner Date NS BOOP, D. SANITARY Y N
RECOP p
WORKMAN COMPIiNSATION DECLARATION S ?RAP SC1100L TA% Y_ N
❑1 hereby affirm that I have a certificate of consent to self-insure, r a RFLEfixT M
Certificate mWorkers Comperuation lnsuanaora certitkd ropythem.! c. pA.SY 1 C. O S ITS Y N
3800,lab C.) PARK
Paltry a RECEIPT M
Cam any GAS EA. V 4 ) BUILDING CEIPTNSIONF[ES
am
ed copy lsherebyth the ed.city GRFME L ASTEI CEPTOR PLANCHECK FEE
ertRled copy ls filed with the city Inspection division. �J t( /'1'f/
CERTIFICATE OF EXEM PTION FROM WORKERS• GR PAID 10*6 SIOKS
COMPENSATION INSURANCE SEWER ARY RM EA ZOOFT Dale Remi f# ,� —"
(I'hlesection need not be complded lithe permit n foromehundred dollars
($100)orlm.) WATERE ATER W/VENT/ELecTR ENERGY FEE Y N
I cartify that In the performance of the work for which this permit is Lssued, —
I shall not employ any person In any manner an as to became subject to the
Workers Compensation Laws of California. Date ." WATER SYSTEM/TREATING PAID '/
Z Applicant NEW RESIDENTIAL PLMB. Dale RCCCI f#�O• OD
Z O NOTICE TO APPLICANT.If,after making this Certlflcateof Exemption,you SQ.EG
Fshould become subject to the WorkersCompensation provisions ofthe Labor TOTAL: 2
CC N Code,you must forthwith comply with such provisions orthls permit shall be
> deemed revoked. BU E 50
LU
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hercbyafOrm that there is a construction landing agency for the perform- a-� ELECTRIC FEE
(�L) Z ance Landerlhework for which lhls permit is Issued(Sec.3097,Civ.C.) TOTAL' L PLUMBING FEE t�
O Landers Name
ILF Lmder.Adaress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O,
O W IredrtythAIhmvereadthbappliatlonandstatethAtheelterl- formation
1 lscorret.l a gree to comply with all city and county ordlnanresand elate laws , PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives.phis
F— Z city to enter upon the above-mentloproperty(m Wp.ped..purpaxre. ALTER OR ADD TO MECH.
md Dale Recei
V — (We)agree to save,Indemnityt#an d keep barmier the City of Cupertino P
agmuslin bllitics,}rdgments,carts and expenses which may In any wayaarue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag.inst id In consequence of the granting of this permit
AIR HANDLING UNIT(OVER 10,000 CFM) C CONSTRUCTIONTAX r
SignmouLreo ApplicanxILontrector Data I EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAA R DODS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha ad le harardom HEATING UNIT(TO 100,00D BTU) Dale RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iicalthand Safety CadSection 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1YenNo
Willtheappllcant or core building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSIPATE
which emit hazardous air motaminant.an defined by the Bay Area Air
Q.tthty Management District? BOILER-COMP pts OR 100,"BTUs
4 Yes yNo
have read the haza us materials requirements under Chapter 6.95 of BOILER-COMP(OV1R 100,000 BTU)the
NOVr 3 U ' '
the Califomla Health k Safety Code,Sections 25505,25533 and 25534, I N
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.PT.
responsibi ltyt mtitytheovcupantoftherequirementswhichust be met asra,.a(,A..rarts�jMR
Fri rer ols an fa C Illate.(Occupancy. 4 M` {s�j�W {411130e Wav
♦ o
Ow aulhoM dg tI DIte
TOTAL: Q, ISSUEDBY:_ l O ULC
OFFICE COPY