21530 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
11-21lding Project identification 7 PERMIT NO.
Building Address: t t 21530
�2�j f�t lA)o1��1� S�QCr pfI CA2DL S ICc
4JwnersINante: one: APPLICA IION SUBMI I I p
CITY OF CUPERTINO-BUILDING DIVISION
GadtrSNoLi=N APPLICATION / PERMIT 90
BUILDINGEnECTRICM1 PLUMBINC-MECHANICAL CATEGORY CONTROL
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERNITISSUANCE � � ❑ � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(cemmene APPLIANCESRESIDENTIAL _ JOB DFSCRUMON
ingwith Section 7000)of DtWsion3ofthe Busimmand PmfmsionsCode,and my '
license is in full to.and effect I PANES
Limnx ClapN�
Dne_1e9o7{afr_s Contractor
ARCHITECTS 'C RATION 201.1000 AMPS
pw re0 77 I understand my plans shall W used as public records. OVER 1f100 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
E Licensed Profe.loml ' SIGNS ELECTRICAL
id
fn< OWNER-BUILDER DECLARATION SPECIALCI2CUIT/MISC (�
i.., Thereby of@m that l am exempt from the Contractors License law for the
OZOv+.'� following resson.(Section 7(13I$Bwinessand Professlons Code:Anytlty,or 111,1P.METERORPOLEINST.
5 u9 muntywhic requ sapermlttomrutmMalter,impmvelLL
,demh,orrepalr
P anystme mpdortoitsmancgalsorequlreatheapplicantforsuchper tto POWER DEVICES
Uilk a signed statement that he Is licensed pursuant to the provisiom of the
Contractor's Liceme (ChapterLaw 9(commencin with Section 700D of Divi- VALUATION
OOn (commencing ) SWIMMING POOL ELECTRIC
O sbn basis to the alleged
exemption. Any violatorthaion
n of exempt therefrom and
Sr'S the basis for the alleged exemption. Any t to.
con of Section 70IIS by any ! ry
Q �$ OIJILETSSWITCFIFSFIXTURFS �U�7
appilwntfora permit subjects the applicant toe dull penalty area morethan
I•` five hundred delta.($5M. NEW RESIDENTIAL ELEC7R SQ.Fr. STORIES TYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sok
�7a compensation,will do the work and the structure b not intended or offered for
5 0 vie(S.c.7614,Bu0novsand Profemioru Code:The Contractors License law
$g does not apply to an owner of property who Wilds or improv.thereon,and OCC.CROUP RFS.UNITS
who does such work himself orthrough hisownemployces,provided that such
Improvements arc not intended oroffered forsale.If,however,thebullding or TOTAL: L
Improvement issold withinomyearofcompldlon,theowner- flderwill have
the burden of proving that he did not build or improve for purpose ofsale.). QTY. PL BIN PERMIT FEE FLOOD ZONE APN
F]Las owner of the property,am exclusively contracting with licensed PERMI SSUANCE
contract..to construct the project(Sec.7034,Business and Professioru Code:
The Contractor's License Law does not apply to an owner of property who �.TpR-D N k WATER ffNN
Wilda or Improves thereon, and who contracts for such piojects with a FEE SUMMARY
c9a4actor(s)licensed pursuant to the Contractor's License Law. BA FIA T.D CE
L�I am exempt under Sec B 4 P C for this reason OUTSIDE FEES
DRAT R R F REA,COND. SANITARY Y_ N_
• Owner Data RECEIPT N.
WORKMAN COMP ENSA DECLARATIONYER TAN \\MW4SCI100L TAX Y_ N
❑1 hereby slflrm that I have a certiRret,rate of consent t.self-inmre,.r a RECEU'f N
certificate ofWorknes Compensationlnaurance or a certified mpythereof(Sax. G BY I CAOIITLET PARK FEE Y N
38(D,Lab
policy N G ER 4(FA) RECEIPT#
Coma BU ILDING DI VI SION FEES
�CartNed copy b hereby fatmhhed. SE/IND Lwp TOR PLANCHECK FEE
MComfied ropy b filed with the city Inspection division.
CERTIHCATEOFIXEMPTION FROM WORKERSFASEIRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY- Al 4k 20OFT Date RCCe{ t#
(This section need na be completed If the permit is forone hundred dolls.
($100)celess.) WATER BEATER / /ELECTR ENERGY FEE Y_ N_
I certifythat In the performance of the work for which this Ferrell,Is heated,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/ EATING
Workers Compensation laws of California.Date PAID
TICE TO APPLICANT:If,site,making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQb7. Date Recei t#
plicant
Z Z NO
H0 should become subject to the Workers'Compensation proWbm.(the Labor TOTAL:
W Code,you must forthwith comply with such provisions orthb permit shall be, BUILDING -
cc U)
revoked.
EE
IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d
I hereby affirmthat there b a construction lending agency for the perform- E F
ELECTRIC E
TOTAL: EQ
Z ance of the work for which thin permit b Issued(Sec.3097,Civ.C.) ELECTRIC EEE
(� O Lender.Name
LL ~ Landes Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icerti/ythatl havereadthhapplicztionand statethatthe Arrive Information
0 W bmrrect.1,wartocomplywith allcityand countyordtnanresand data laws PERMIT ISSUANCE FEES PAID:
} M relating to building construction,and hereby authorize representativesofthb
I.- U) cityto crucrupon the above-mentioned property for Inspection purposes. ALTORAODTOMECH. Date Receipt#
(We)agree to save,Indemnify an d keep baroness the City of Cupertino
V against liabilities,Pigmen4,c.Gsand expenseswhich mayln anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalint said City in consequence of the granting of this permit. AICONSTRUCTION TAX
R HANDLING UNIT(OVER t0,000CI•M)
x CONSTRUCTION TAX PAID:
Signature of Applirant/Contactor Date EXHAUST HOOD(W/DIX:T)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,IX10 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealthand Safety Code 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: - 7
❑ Ye No
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSATE
which emit hazardous air cents minants as defined by the Bay Area Air w�a-�w
Quality Management Dbt BOILER-COMP OHP OR 100,000 BTU)
4Yes No TTY Q n
havercadthehaza o sit tonalamquhe under Chapter 6.95 of MOILER-COMP(OVQt100,DDD BTU) NEC I U 19 0
the California llcalthk Salety Co ctions 75533 and 25534.1
understand th of Vldi�, otcurr tl aveatenanq that ltbmy NEW RISIDfiN77AL MECH. SQ.ITresporoib" .tifyf 1h rementawhichmustbemetprior to ora 9. ...1wr
rise c / l,e IS5UEDBY: �9N7OLJCGI
TOTAL:
OFFICE COPY