21108 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY k D TO
Building Project Identification PERMBTNO.
Building Address:3 7S D �a L k ° -r g � 21108
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APIA
C_V&V P CITY OF CUPERTINO-BUILDING DIVISION. /Lic.No APPLICATION / PERMIT
Archlt En nc BUILDING-ELECnUCALFLUMBING-MECHANICAL CATEGORY CONTROL M
g� gr' — Llc.No:
��/• QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERM IT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby
thb ioflmnlhatlam Bcensefthe under Buinese;provisions Cha pier9(commrnc APPLIANCES-RESIDENTIAL JOB DFSCRBaTTON
Ingwith SMIon7000)of Dlvlelon3olthe Buelnea°yyxpol'rofesslonsfode,and my
licenseisin(uI o and died. / I PANELS SF.�w L,
License C6 Contra-'-3
Date Contractor,
ARCHITECT'S DECLARATION 20-10DOAMPS
I90 ZO ]understand my plan shallbe used aspublic reooedL OVER 1000 AMPS SQ.FC.FLOOR AREA S/SQ.Ff.
Licensed Profeulonal SICNSELECTRICAL e�2 ///
�61 OWNER-BUILDER DECLARATION SPECIALCIRCNT/mils( 7 "TTT
7 � IherebyafBrm that l am exempt from the Contractors License Law for the (h�j`
pp following reason.(Section 7031.5,Business and Professions Code:Any city or
gcy county which requiresa permit tororutmct,alter,Improve,demollsh,or repair TENIRMEIPRORPOLEINST.
q°� ❑a nystm=mpriortoits Lsuance,alomquimatheapphantfnnuchpea do
P U file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
SOu Conind.e.Licenselaw(Chapter9(mmmendngwlth Sealon7000)of Divi•
OS don3ofthe Bu.Ines.md Pro(emlmaCode)orthat hebexempilherefromand SWIMMING POOL F7.ECITtIG VALUATEOjJ®
S°-t the basis for the alleged easmptfon. Any violation of Section 7031.5 by any 1
< applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHESFIXTURES LPI
five hundred dollars($500. ' lel'
nI,as owner of the property,or my employees with wages as their sok
NEW RESIDENTIAL ELEC7R_SQ}T. kFLOO�D—ZO:NE
ES TYPE CONSTRUCTION
5,10
compensarion,wllldothework andtheatructure bnm intended or offered for
S 1❑ sale(Sec.7044,Bualness and Profeesdons Code:The Contractors License Law
EW does nor apply to an owner of property who builds or improves thereon,and ORFS.UMTS
whodoessuch work himself orthrough hisownemployees,provided that such
Improvements am nm intended oroffred for sale.If,however,the building or TOTAL; QL (Z--3
Improvement is sold withinoneyearofcompletionthe mwner-bullderwBl have
tl�(uMen of pmving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE APN
Lj t,as owner of the property,am exclusively contracting with licensed
cont-cera to construct the prefect(Sec.7044,BuslneveM Profesaloro Code: PERMIT ISSUANCE dye
The Contractor's License Law does not apply to an owner of property who ALTER DRAIN kVENT-WATER(EA)
Wilds or improves thereon,and who contracts foe such plojeN with a FEE SUMMARY
ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under See B k P C for this mason
RECEIPT R
OUTSIDFF
Owner
LF+NAtA N SANITARY Y N
• Date
WORCOMPENSATION DECLARATSCI
C:11 hereby affirm m that that 1 have a certlflute of consent to sett-Insure,ora IOOLTAX Y NRECEIPT N
3800,Lab
C.)aof Workers'CompensatlonIrounnceoracertl(led copylM1ere°f(Sec.
3800, G EA. .10 PARK FEF. Y_ N
Policy M RECEIPT R
Com any GASO�'EM-OVER4 ) BUILDING DIVISION FEES
Certified copy is hereby furnished. GREASE/G)DUSTRL WASTE INTERCEPTOR74
PLANCHECKFEE
Certified copy V flied withh the the city Inspection division.
CERTIFICATE OF IO(E'MPf[ON FROM WORKERS' GREASETRAP PAID [�,atarA
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200IT. Date Retmi t# J
(fhls I.on need mat ed completed lithe pemNt V fororle hundred dollen a Vv
(flm)nrlyth WATER HEATIR W/VENT/ELECTR ENERGY FEE Y N
lartlfythat Nthe per(omanceof the work forwM<h this permit le ma,ed, —
I shall vol employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
OZ NOTICAppilraE NEW RESIDENTIAL PLMB. SQFT. Date Reoel tic
Z O NOTICE TO APPLICANT.1,after making this Certificate o(Ezemptl°n,you
HIhouldbeccoesubjecttothe W°rken'Compematlon provisions of the Labor TOTAL:
y Code,you must forthwith comply with such provisions orthb permit shall be r JL oD
> deemed revoked. ENG FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyafim,that there Is a construction lending agency for the perfmrro- ELECTRIC FEE Q
00
Q aneeoftheworkforwhichthis permit is Luued(Sec.3097,Civ.CJ TOTAL; 7A90
(� Lender.Name PLUMBING FEE 7aQX
IL I— Lender.Add mss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE "70a
OU Icertifythatl have mad this appliatlon and ltatethaitheaboveinfornalion ^ ,ss�
W L+mrmd.I agree to comply with all city and county ordinances and mate laws PERMITISSUANCE ILCD FEE$PAID:
O- relating tobulldingeonslruction,and hembyauthonas representatives of this
F Z cityto enterupon theabove-mentloned property for Inspection purposes. ALTER OR ADD TO MECH.
agree ins uve,Indemnify an d lees armlets the City of Cupertino Date Retei tH
agaWthabil ,)udgnsnt eteand rases Ichmaylnanywayaocrue AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL-!-!
again Ityin cons enceo gr olio flhls pemnit.
Q AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Igwtore Appian/Cont ctor ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WII the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel tit /
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 1°0,00)BTU) TOTAL:
as
❑ Yes r)No
Will the applicant orfflum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$ ATE
which emit horn dous air contaminants as defined by the Bay Arca Air
Quality Management District? BOILER-COMP OFIPOR 100,000 HIM �a,rs
'?hYa No �Na U
aveneed
Health
Safety
Code,Se requirements 5533undand 2554. 1 of BOILER-001\0(OVER100,00)BEV) lB D
the Californiala Health k5afety Code,Sections 25505,25533 and 75536, I
understand that if the building don not currently have a tenant.that It is my NEW RESIDENTIAL MECH. SQpT
responsibility to notify the occupant of the requirements which must he mei nr,7t I) o
prior to Issuance of a Certificate of Occupancy, au 1...55 s�A,a
Owner or authorized agent Data ISSUED BY: irN-a x•1.1
TOTAL: O
OFFICE COPY