21281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification I PERMIT NO.
Building Addrcu:
Z 8z c� A-L-00-rciRILE- saU-U�w . 21281
are: one:
4.31 TICITY OF CUPERTINOQBUILDING DIVISION
Crntiaclur'a Name: Lie.No: APPLICATION / PERMIT
1 BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL Y
Arehiteet/Engineer. I Lie.No:
L7 a QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcu:
PERMIT ISSUANCE L ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ` LIS
I hereby affirm that l am Bcnaed under provisions o(Chapter9(rommn APPWANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth5 dion7000)ol DtAMon3ofthe Bustneuand Pmfnslon.Code,and my
li¢nse I.I. fierceand k.# S •�j a PANELS
Dam CkaY�LICY
Uate_fetContractor
RCHITECTS CLARATIO 201-IODO AMPS 1 //
qreOQ lundentand myplaroahallbe used aspublicrecmda OVERIODO PS SQ.FT.FLOOR AREA S/SQ.FT.
q��++ C
Fid(D Licensed Professional ' SIGNS ELFGTAfGcAL
<6 OWNER-BUILDER DECLARATION 0
��3 SI'[CIAri,,CBtCIHT/MISC
p, Ihercby affirm that Tom exempt lromtheContnctor' 'cense law fmthe
following reason.(Section 7B31S,Buslnns and Profeas Code:Any city
OR- .TEMP.MPTEROR POLE INST�
ria county which rcqulresa permittrtonstroct,site,impro of
such,orrcpalr
< a nystm=mpdortolt tmam.,4 requlrestheappu rat for ouch pemdt to �� POWERDEVICE
aX U file a signed statement that he k licensed pursuant to a prrQQvisinns of the
Or'((.. Contractor's License Gov tChepter9(mmmencingw �(ySect16n7000)of Divi- Ir t.
30J slon3ofthe BuakesancIPro(easWroCode)orthngo pempltherc(romand SWALWN LELECTRIC / VALUATION
Q.•77 the basis for the alleged exemption. Any viols o!S k o 7m L5 by any O E TCIiFSFI ES 4��
applicant fora permit subjects the applicant to a vll'phmltytof nor=to than
$J five hundred dollen(4500). SQ STORIES TYPE CONSTRUCTION
,4 Ci /11..] R '� NEW RE$DEMIAL EL TR Ff.
�n �1,ae owner olthe property,or ryeers wlthwagnathak min _
compensaHon,wllldothe wmkand
beat ctuhnctlnknded or'offered for 9
Osale(Sec.7064,Business and Prol.k.Code:The Contractors Weise Law
r3$ does not apply to an owner of property,who Wilde or impravn thereon,and 1 mOCC.CROUP RFS.UNRS
66 whodan such work himself or through his own emplayroypiovldet that such
Improvements
arc not Intended reoffered for oak.If,however'thebullding or TOTAL:
improvement asoldwithin oneyearofcompletlomtheownerW Werwlll have
try�urden of proving that he did not Wild or Improve for purpose ofeak.). QTY. PLUMBING PERMIT FEE FLOOD MINE APN
LJ w
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to co ntruct the protect(Sec.7044,Busuese and Professions Code:
The Contractors License law don not apply to an owner of pmperty who ALTERDRAIN&VENT•WATER(EA)
Wilds or Improves therm, contracts and who contfou -
such ppoces,with• FEE SUMMARY
cy)kador(Q Ilnnnd pursuant to the ContractrYa License Law. RACK FLOW PROTECT.DEVICE
1_J I am exempt under Sea B&P C for this reason
ner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
y® Ow
WORKMAN COMPENSATION DECLARATION RFCEVrNFIXTURES PER TRAP SCHOOLTAX Y N
hereby affirm,orkers that 1 have o ce tificatesuranc of consent to op therre,ora RECEIPT.Y
¢rtlficete of Workers Compensatlmlnsurancemacertllled ropy therco!(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Isis C.7 / `-.f br-'•Tj� �� O RECEIPT
Pal
iryN lZ C GAS EA.SYSTEMOVER/(EA)
Com any BUILDING DIVISION FEES
EDCrefied ropy herbyththe city
GREASE/INOUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�eeflfied copy is filed with the city Inspectbn divlelm,
CERTIFICATE OF]IMITION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE
(This section cared not becompleted lithepermit is(Drone hundred dollars SEWER-SANITARY-STORM EA.20011r. Date. Recei tit
m I cemlees.) WATER HEATER W/YEN./ELE:.T.R ENERGYFEE Y N
I cent em t o the person in an the work(or s to becomeis
based, — —
I Whale not employ any person In any manner n u to beronte subject to the WATER SYST.FM/TREATING
Workers Compensation Laws of California.Date PAID
Z Z Applicant
NOTICNEW RESIDENTIAL PLMB. SQFf. Date Recd til
O nt AI'PLICANTa,after making this Certificate of Exemption,you
shred become subject to the Workmd Compereatio,provisions of the Labor TOTAL:
CC 0 Code,you must forthwith comply wlthsuch provlslons orthis permit shall be pUILDINC
W 7 deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
a C IhercbyafRrm that there is a construction lending agency for the perform, ELECTRICFEE
Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O
Lender's Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OLO Imnlfythat l have read this applicetlemand statethatthe above Information
1 Iscorrect.I agmeto comply with all city and county ordinances and gate laws PERMITISSUANCE FEES PAID:
N relating to building mrutroctlon,and hereby authorize representatives ofthis
(— city to enter upon the above-mentioned props tan pas ALTFRORADDTOMFCH.
V ? (We)agree to save,lndemnlfy an d kc semis e ty of upertlm Date
Recei t>
agalnstlkbNtkro,jsd fients,cost dexo uaw ch msin
In
nyw yacaue AIR]iANDLINC UNIT(TO 10,000 CFM) SUBTOTAL:
agaWteald Citi onsaque o(the granZ (ihls ffornI AIR HANDLING UNIT(OVER 10,OJOCFM) CONSTRUCTION TAX
Slgnstumot punnt/Contractor v to ExHAUS'f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date Recei tN
material adefined by the Cupertino Municipal Code,Chapter 9.12,and the
Healt Yen Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTI!) TOTAL: 7a
Ili the applicant]) INP building mm pant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontaminsnta as defined by the Bay Area All
Quality Management District? BOILER.COMP(311POR 100,0()BTU) ��
Yes I�Nr 6$
ave¢adthehazar�wsmaterlals requirementounderChapter6.95 of BOILER-COMP(OVER 100,000 BTU) '
the Ca Ofcmk Health&Safety Cod,Sectlo d2553d. I //
understand that ifthebulldi on not r nllyhav rant,that It is my NEW RESIDENTIAL MECH. SQFF
responsibility to ctify th pant erequl cab which must emet IJJJ
Imartoissu o!a ceteo pan �/-�s,•��� (F
Dwncr or authoduM agent Pat. TOTAL: ISSUED BY:
OFFICE COPY