21499 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
I o T 2
��zEs 21499
_ 5_ GJEs
wnere one:
IYJml � G[ CITY OF CUPERTINO-BUILDINCDIVISION
Cente / me APPLICATION / PERMIT / 130—
0— O6 V
A1111111, BUILDINGELECTRICAI PLUMBINGMECIIAMCALCATEGORY CONTROL N
sawArchitect/Engineer: Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 67/ 1pS PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Hureb affirm that l am Hiceued under mvWansof Cha r9(commet APPLIANCFS.RESIDENTIAL
Y P pie JOB DPSCRI'TION
Ingwlth in
7000)ofDiv(alon3ohhegualnenandProlessionsCmde,and my
acerae la In ful d drect. PANELS
Llren corrector
p 3600 nn,�
Date
ARCHITECT'S
WN 201-1000 PS
ARCHITECTS DECLARATION
pz Iunderstaod my plaru ehallbe usedn publicrewda OVER AMPS SQ.FT.FLOOR ABPA 5/SQ.FT.
O
dLicensed Professional SIGNS TRI
6� OWNER-BUILDER DECLARATION SPEP�AL C /MMs
ZE, 4 Ihereby affirm that am exempt from the Contractor's License Law forthe
O RF following reason.(Section 7031.5,Business and Professions Code:Any dryer OR Sf.
Appp countywhichmquiresaper ttocomtmct,alter,Impmve,de=lWh,ormpal
440 anyamorme prlorto its Issuance,also requiresthe appllcantfonuch permitlpt ro fCEg
file a signed statement that he h licensed pursuant to the proWlons or this,'
ati Contractor's License Law(Chapter 9(commencing with Section 7000)of DIv1- NG L ELECTRI
slen3 ofthe Buslnessand PmfemWroCode)orthat he ls eumpt tharefot d VALUATION
o the basis for the alleged exemption. Any violation of Scnbn 7QI7.5 by any ; E HFSHXTf/R
appllcmt fora permit subjects the applicant to a civil perulty of net more In
five hundred dollars(x500).
.� -
Z�n ❑f,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.PT. STORIES IYPECONSTRUCUON
c mpenvtlon,wllldothewwk,andthestmcturefao teMedoroffemdfo
HM In(Sec.7044,gusinns and Profembtu Code:The Comraaoes License law
does net apply to an owner of property who builds or improves theme,and - ✓
e. who docs such work himself orthrough hlsown employees,provided that such OCC.CROUP RIffi.UNITS
art not Intended or offered for sale.If,however,the building or TOTAL:
improvement Isaold withinone yearofcompldion,theowner-bullderwlll have
thqurden of peovingthan he did not build arlmprove for purpose ofub.). QTY, PL BING PERMIT FE
FLOOD ZONE APN
LJ L as owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Prof coloru Code: ,0'1)
The Contractor's License Law don net apply to an owner of property who
builds or Improves thereon,and who contracts for such p(opoe with a ALTER-DRAIN&VENT-WATER(EA)
c ra4actw(s)BrenrW pursuant to the Convenor's License Law. FEE SUMMARY
LJ I am exempt under Sec. 8&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date n RECEITp
WORKMAN COMPENSATION DECLARATION V FD`TURFS PER TRAP D O SCI100L TAX Y N
c2❑I hereby affirm that I have a certlfiPate of consent to elf-insure,ora RECEIPT N
cateofWorken'Compeutimlmunnreoraoertifkd mpythereof Cee. GAS EA.SYSTEM-1 INC./OUTLETS PARK FEE Y N
3800,lab C.)
Policy N RECEIPT N
Com n4, GAS F.A.SYSTEM-OVER4(EA) BUILDING DI VI SION FEES
[Certified ropy B hereby fumiahed.
C3 Certified copy isfiled with the city Impaction division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE'A'SE TRAP PAID
COMPENSATION INSURANCE SEWER-SAM'fARY STORM EA 200PI' Date Remi ted
(This seMon need not be completed B the permit is former hundred dollars
($10forless.) WATER I,IFS.I.ER W/VENT/ca Fr.I.R ENERGY FEE' Y N
I certify that in the performance of the work forwhlch this penult b heated, —
I shall not employy��ny person In any manner so as t9 eco IDsbje j�e WATER SYSTEM/TREATING O PAID
Workers Comp
Laws ml Call .Dale r. , Q
llos�
Z O NOTICE TO lLICANT:Merl ma king this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT. Date Reeel t#
Fshouldbeco subjectloth orkers'Compereatfon provisions of the Labor TOTAL:
N Code,yau at forthwith comply with such provblorumrthla permlbhall be -.BUILDING W 9 domed revoked 2-3 CONSTRUCTION LENDING AGENCY MIC FEE
CL I hereby affirmthat there is a construction lending agency for the perform- ELEC'T'RIC FEE
an ce of t work for which this permit Is issued(Sec.(Sec.3097,Cis.
TOTAL:
V O [cedar's Name
Name PLUMBING FEE .d
LL F Lender's Addrev QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl have read this applicationand statethatthe above lnfornotlon
IL iscoreen.T agree to comply withal1 cityand muntyordinanrce and state laws PERMIT ISSUANCE FEES PAID:
se
W relating to building construction,and hereby authorize representatives of thin
F_ U) city to enter upon theabovcmentkamd property for impaction purposes. ALTER OR ADD TO MECH.mnDate RCCCTPI#
_ (We)agree to save,led elfy an d keep harmess lthe City of Cupertino
against hatellilles,Judgments,costeand expenseewhich may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
gave said City In consequence oft granting oftMs permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
��vr ,
-4' //-3� s'
Si mm.fAp Ivnt/Contactor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe ppllontorfuturebuildingoccupantaloreorha Mlehazardoua HEATING UMT(T0100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCMP Scnioa25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ,Q
❑Yea No
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
hich emit hasardous av contaMrunb as defined by the Bay Arca Air
(u I,lty Management District? BOILER-COMP 0HP OR 100,000 BTU) NOS
No
Yhave read the haze ous minerals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. 1 �� /1
and erste ad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECFI. SQ.FT NI
responsibility to notify the occupant of the requirements which must be met
prior m issuance of a Cedifimte ofOccupancy.
Owner or aulhwlud agent Date C
TOTAL: ISSUED 6Y: 01 let
` OFFICE COPY