21496 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proem Identification PERMIT NO.
Building Address:
W. 1 21496
where antLe:
�s,,.Qc ane: A A
1�l�7 CITY OF CUPERTIN66UILDING DIVISION � �r�o�O
II tr.dm`.Name: Lie.No: APPLICATION /PERMIT "L
LVPSaC F'ONST.eE7G /Oh OULDING-ELECnUCALPLUMBINGMECI NICAL CATEGORY CONTQOI,J, O
r himet/Eegineer. Lic.No: �O J .�
L7_F:. k,TT BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: PERMTISSUANCE PLUMB NSI�H
LICENSED CONTRACTOR'S DECLARATION 0
Thereby affirm that l am licensed under provisions of Chapter9(mmmmc APPLIANCES-RESIDENTIAL JOB DESLMON
Ingwith Section 7000)of DiAsion3ofthe Businessand ProfesalonsCde,and my I
11 ss le infuEfmosseddfed PANELS POOL)
cemeClas� LIe.M �/�1([Gt
Date ,Contm,m OAG �G�av 21 O2DOAI'S
ARCHITECTS DECLARATION OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
I understand my plans shall be used u public records
k Licensed Professional SIGNS ELECTRICAL
t;z ffiOWNER-BUILDER DECLARATION SPECIALCIRC6T/M J LiIJ
t- Ihereby arm thatI am exempt from the Contractor's License Law for the
700 ❑ following reason.(Setion7MIS,Businessand Proddedons Code:Anydtyor gyp,M OR I
2 ip'W coontywhich requires a permittocorotruct,alter,Improve,demolish,oreepair
anystmNmpAortolts LasuancgahorequirestheappU=ntforsuchpermino TgWERD
a CFU file a signed statement that W b licensed pursuant to the provisions of the
O w G Contractor'.License Iaw(Chapter 9(commencing with Section 7000)of DIN- SWIM NG L E C
30 elon3ofthe Bueine.amd Profe.lons Code)orthathebexemptihemfromand VALUATION
g o the bash for the a leged exemption. Any violation of Section 7A 1.5 by any
5_0
applicant fapplicant ora permit subjects the applicano a civil penalty d not momthan
$ five hundred dollars($SM. NEW A TR SQ.FT. STORIES TYPECON'STRUCUON'
�j..
F11,as owner of the property,or my employees with wages as their sok
�7Q Compensation,wWdothe work,and thestructure b not intended or offered for
5
Is(Sec 7(N4,Business and Profeniors,Code:The Contractors License Law
$ does not apply to an owner of property who Wilds or improves thereat,and
as^ who does such work himself orthrough his own employees,provided that such OCC.GRDUI' RES.UNITS
Improvements arc not Intended oroffered forsale.If,however,thebuliding ce TOTAL:
Improvement sold wlthinoneycaro(completion,the owner-W Bderwill have
(hr„JluNen of proving that he did not Wild or Improve for purpose of sale.). QTY,PTER-DZIN
ING IT FEE FLOOD ZONE AI'N
LJ L as owner of the property,am exclusively drol—Ing with I—— E
contractor.to construct the project(Sec.7014,Business and Professions Code:
The Contractor.Lt...Law does not apply t......r d property who ATER(EA)
bullets or Improves thereon,and who contracts for such ptojects with a
do a)licensed pursuant to the Contractor's License Law. BACK FIAWPR tDEVIGE FEE SUMMARY
U I am exempt under Sec B k P C for thin reasonOUTSIDE FEES
DRAINS FLOORR F,AREA,COND. SANITARY Y N
Owner a Date RECEII'1'p
a WORK MAN COMPENSATION DECLARATION FIXTURES PER.TRAP SCISOOL TA% Y N
QI hereby affirm that I have a certlRate of consent to self-Insure,ora RECEIPT C
certificate of Workma'Compensation Insurance or a certified copythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE. Y_ N_
3500,lab CJ
Policy I RECEIPT a
Co any GAS EA.SYSCLM-0OVER BUILDI NG DI VI SION FEES
ffCerified copy b hereby furnished. GREASE/INDUSfRL LIABLE INTERCEPTOR PLANCHECICFEE
MCehified ropy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ��yy�� p[yyxx
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA MET Date 'Ci t#—1•J�
(fhb section need not be completed if the permit b fou one hundred doll..
($100)mlc..) WATER HEATER W/VENT/ELECTR ENERGYFEE N
1 certify that N the performance of the work for which this permit Is heated,
I shall not employ any person in any manner ec as to become subject to the WATER SYSTLM/TREATING
Workers'Compena.tion Laws of Csllfomia.Date PAID
C<Z Applicant NEW RESIDENTIAL PLMB. SQ.ET. Da[ Revel t#
Z NOnCETOAPPLICANT:ILaherm.kingthb CedtflCate of Exemption,you
Fshould become subject to the Worker'Compensation proXims of the Labor TO L:
CC W Code,you=9 forthwith comply with such provisions or this permit shall be BUIL
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC 'E- lobw
a (hereby WimHhalthereb...tructimn leedingage.ey for the perfemrm TOTAL_ ELECTRIC FEE
M Z ante of the work for which this permit is,Issred(Sec 3097,Civ.C) PLUMBING FEE
LL O Lenders AddNamTY. MECHANICAL PERMIT FEE
LL U lender's Address Q MECHANICAL FEE
U Icertifythmeto have
comply is with
alimtynanduntyordina the above dinformation
O W bcormct.1.greemcomplywlthat[lcityand countyonflnancelandgate laws PERMIT ISSUANCE FEES PAID:
} 0) relating to Wilding construction,and rcby authorlu repreaenietivea of this
F Z Wcity to enter upon the above-mentioned property,for Inspection purposes. ALTFRORADDTOMECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino V AIA HANDLING UNIT(TO 10.030 CFM)against lubilitim,pdgments,costs and expense.which may in anywayacaue SUBTOTAL:
ago' aald
cityi naequenceaf grantijithls permit.
460AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
um of App nt/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apph.nt or future building occupant store or ha ed le handous HEATING UMT(TO100,030 BTU)
aaDate Recei t#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
I kalth and Safety Code Section 25532(a)7 HEATING UNIT(OVER IXIOW BTU) TOTAL: 1
0y. ri No
Willthe applicant or future Wlldlegoccupant use equiprrent ordevicns VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent ha,rardoua air contaminants as defined by the Bay Area Air
Quality Management District? BORER-COMP QHPOR 100,000 BTU)
4Yrs No �]J/.A
hyvemadthe h �usrute a req lrcmensunderChaper6.95of BOILER-COMP(OVER100,00087U) ry^tt' 4jo
the California Health h Safety Code,Sections 25505,25533 and 255A. I Y'/
�= understand that if the building does not currently have a tenant,that It N my NEW RESIDENTIAL MECIB. SQ.Ff. 0ul
responsibility to notify the occupant of the requircerents which most be met r j
prior to Issuance d a Certificate of Occupancy. •� Vf
Owner or authorized agent Date TOTAL: ISSUEDBY: a'
OFFICE COPY