21596 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERNTENO,
Building Address: a Fead aw s l r�q6_�,� 21596
me: one: A A
CITY OF CUPERTINO-BUILDING DIVISION
fide Na , �' Lic.No: APPLICATION /PERMIT —�
BUILDING-ELECTRICALPLUMBING-MECHANICAL 12—Y-1 0N7ROL#
Architect gine: Lie. o:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ o ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that lam licensed under provisions o(Chap<er9(commenc- APPLIANCISRESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Dlvidon3ofthe Bud eessand Professllf COde,and my
li=,Cln dfed. PANELS / IA
License Cb ICM �VY`
Date� UP TO 2DOAMPS
�HITSmursemorT l n C_ 2o1-1000 AMPS YYYYY�t�`
Rs.hall CTR DECLAR TIC- OVFRIOOOAMPS SQ.FT.FLOOR AREA E/SQ.FT.
�'l. I understand my pha shall be used u public records.
O
X Licensed Professional SIGNSELECTRICAL
L
-1 OWNERFf
UILDER DECLARATION SPL3LCItCU1T/MISC
Thereby affirm that lam exempt ContractorsG
the Contractors Llcenx wfor the
O F.0 following reason.(SeMIOn 70315,Business and Profession,Code:Any city or TEMP.METER OR POLE INST.
rc, p,a county which rcqulrm a permit to construct,alter,Improve,derrnlbh,or repair
<'y�..l anystruMure prior to its lusuance,also requlresthe applicant for such permit to POWER DEVICES
K 1 file a signed statement that he is Banned pursuant to the provisslom of the
3q� Contraaar,License Law(Chapter 9(commencing with Section 7DOD)of Divi- SWIMMING POOL ELECTRIC VALUATION
O sion3otthc Russ.and PrefessioaCeddorthat he b event there(romand
V',^i the basis for the alleged exemption. Any violation of Section 7031.5 by any
FOUTLETSSWITCHESIq%TURFS
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred doTlof the property,
NEW RESIDENTIAL ELECTR SI SIDRUS TYPE CONSTRICTION
Z� L as owner of the property,or my employees n with wage as offered
sole for C < com(Sec,7KBusEosWworkandthes Cdurebra Intended o License
Law
O salesnot 7044,to BusinessandIRdessba Code:The or improves
Lerson Taw
K$$ dont not apply torn owner d property who Wilds orrimprovvided t oRand hat such — OCC.OROUP RFS.UNITS
EE
who domsuch work himself edothrough hbown employees,ILlocseverthelsoldIngor
improvemnnb are not intended oroffercd for sale.If,howeveq the Wlldingm - TOTAL:
Mprovement b wld within oayearof<omplMlon,the owner-bu0derw111 have
UF-4urden of proving that he did not Wild or improve for purpose of We.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ronizacton to ronstrud the project(Sec.7044,Business and Professbmn Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN k VFNF-WATER([A)
Wilds or Improves thereon, and who contracts for such pitojeds with a
ador(u)licensed pursuant to the Contractor's License Law. FEE SUMMARY
I am exempt under Sec B Is P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
15
DRAINSFIAOR F,AREA, yrs SANITARY Y_ N_
. Owner Date )""' / RFLpPf R
WORKMAN COMPENSATION DECLARATION FIX'IURFS ISR ( SC1i00L TAX Y_ N_
❑1 hereby efflrm that I have a certificate of consent to self-Insure,ora RECEIPT#
certi(Icateof Wo @' PI tlon�urane carUfl ropy tFpagof(&c. GAS F.A. .1 C.4 PARK FEE Y N_
3800,Lab C. C (—a/ RECEIPT'#
poltry Y G II )
Com any BUILDING DIVISION FEES
Lj rufle GR INDUBIRL WA I CII'TOR PLANCHECK FEE
�Ctrolled copy is filed with the cit IR n I elan.
• Q CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER- Y- Date RCCCI (#
(fhb section need net be complded lithe permit b forone hundred dollars
'tea ($1m)nrless.) WATER EM/ TR ENERGYFEE Y N
9 l certify that In the performance ofthe work forwhlch this permit b bound, — —
1 shall not employ any person In any manner so as to become subject to the Is SYSTEM/TRG71
Workers Compensation Law,of California.Date PAID
Z Z NOTICE TO APPLICANT:If,after making this Certlfleste Of Exemption,you NEW RESIDENTIAL ELMS. SQ.FT.licant Date Recei t#
O should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
CC N Code,you mast forthwith comply with such provisions orthb permit shall be G
FEE
W j deemed revoked.
d Ei CONSTRUCTION LENDING AGENCY SEISMIC F
Thereby af(irmthrtthercis a ispermwdisued agency the perform- TOTAL ELECTRIC FEE
0 Z arae of the work for which this permitbbsuN(Set 3097,Civ.C)
OO LOnder',Name PLUMBING FEE
F I.endcr'.1Addre„ QTY. MECHANICAL PERMIT FEE
LL
W I If Idgmetoc hbapplication dcountyordlheaboveInformation law. MECHANICAL FEE
bco tl+greemc ply Ith all dtyand rountyrrdiancesand state lawn PERMIT ISSUANCE � .(V FEES PAID:
> 1 n tobuilding n n,and hereby authorize representativmofthis
U) I niers nth above stirred f inspection ALTFRORADDTDMECH. Date Receipt#
~ cry
a fires pm as e,In Pty an property
tF Ciry purposes.
V liabilities gme asan spen whichmaytnanywa a e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
said City in m of Rrapti of this permit.
,Y�/(J AIR HANDLING UNIT(OVER 10,000C IM- ) CONSTRUCTION TAX
u of AppBant ntractort EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS SC SURE
Will the applicant or future building camupa oto orhandlehazardous HEATING UNIT(TO 100,000 BI1p Date Recel t#
material as defined by the Cupertino Municipa ode, Napier 9.12,and the
I Iealth and Safety Code Section 25532(a)7 HEATING UMT(OVER 1001 BTU) TOTAL:
I] Ye, M No
Will theappliont orfumm building occupant use equipment or devices VFNIRATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contamwnts as defined by the Bay Arca Ab PAI
Quality Management District? O)IP DR I W, D
EX0 BTU) m
Ye, No
have read the hoar esus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) * fl IL7Ell1
Pilsility-t.
Bornia Health 1,Sat sty Code,SM Ions 25SD5,25533 and I
.1and that ifthegdon otavrrently havea tenanu b my NEW RESIDENTIAL MECH. 9Q.FT.
nett h pa4tfhe requirements which met /(ss�jasss��/#1�,��as
ua ce0 l Rute o! panty.I 111 Icily of y41
nor or astir agent Dat , ISSUED BY.
TOTAL: a A + r
OFFICE COPY 1(�