21315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITN'O.
Building Address: 21315
/07 zll N. INOLP - 20
wnero arc. one. Avi,LICAnONSUBMIIIAL=A
G�/LLoSMU�/'i� �✓ o7SS•(�aS�O CITY OFCUPERTINOBUILDING DIVISION 10� � •1��R6
contr=am.N•me: J 'I Lie.Na: APPLICATION /PERMIT
BUILDING-ELECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naarca, /b l7S0/51/i-L VP ,
/'--M A/ cJV 3CA9.164AF PERMITISSUANCE 2� ❑ Iii ❑ ❑
LICENSED CONTRACTOR'S DE LARATION �1
I hereby affirm that l am licensed under provisions of Chapter 9(mmmere. APPLIANCESRESIDENHAL JOB DESCRIPITON
ingwith Sealon7000)of Divislon3 ofthe Buslnessmd Prote ed onsCode,and my
license Is In full force and effect. G PANELS 1�N Cwt
LicenseCl nG•4� Lont �.5 J
Data .oj,2, eontrattnr-3 TION pi-1 ODO AMPS
UP TO 2DOA141!S
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
OZ Lunderstand my plassshaBbe used as public records. 6
O SIGNSELECTRICAL s
Licensed Professional
<� OWNER-BUILDER DECLARATION SPECIALCE2CUIT/MI9C
o ; Iherebyaflmathat l am exempt from the Contranor's License Law for the
following reason.13ecilon 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
county which requires a permit to construct,alter,improve,deralbh,or repair
C`•41 anystruchom prim to its Lwunenalso requiresthe appecant for such permit to POWER DEVICES ^
^'C a file a signed statement that he Is licensed pursuant to the provisions c the
Contractor'.License Law(Chapter 9(commoneing with Section 7000)1!Divi- SWIMMING POOL VALUATION
O
1o0o11he Busineae and Profe 1,Code)orthe,he berm Ihllfromand
yd the basis for the alleged exemption. Any ablation of radion OGS see room
by any OUTLETSSWITGHES ES
applicant subjects the applicant penalty of not mare than
five hundred dollars($5M. NEW RESID A A TR
'9..' I as owner of the or m employees with we es as their solecome•'QFT STORIES TYI'ECONSTRUC'1'ION
❑• the
Ye
C < sale satlon,wRldothe work andtheswcture boot Intended or offered for M4 r 1
'S p sale(Sec.7064,Business and Professions Code:The Contractors Lkesse law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.CROUP RES.UNITS
c. who doessuchwork himselforthrough hisown employees,provided thatsuch
Improvements arc not intended oroffend forsale.If,however,thebullding or ty TOTAL: CV
improvementbwldwithinoneyearofcamplelogtMe ner-WBderwillhave
t rden of proving that he did not Wild or improve for purpose afxle.). QTY. PL B PE MIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed CE
contrattora to construct the project(Sec.70K Business and Professions Code:
The Contactors Liceae law don oat apply to an owner of property who .D IN k -WA
Wilds or Improves thereon, and who contracts for such jr,jem with tt AL FEE SUMMARY
c9aipactor(s)licensed pursuant to the Contractor's License Law. BACK WPROTEC .KM
"1 am III under Sec B 4 P C for thin reason
Owner Date
DRAINS FLOOR RTO CO SANITARY RECEIPT
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-insure,or a FIXTURES.PER TRAIL SCI IOOL TAX Y_ N_
certificate ofWorkers'Comperaatlonkssurance ora cartNed copy thereof(Bee. RFOEB'T«
3800,LabC.) GAS EA.SYSTEM-1 INC. OIJTLHTS PARK IIx Y_ N_
Pobry« �7E- 90 �{-/• 9/ - RECE1Prx
Com v GAS LA.SYSIRM-OVER4(EA) BUILDING DIVISION FEES
It Bled copy Is hereby furnished. CRFASE/INDUML WASTE INTERCEPTOR PLANCHECK FEE
❑Cedifled copy is filed with the city inspection division.
CERTIDCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 1WFI Date RCCCI t#
Uhiasectionneedna Wcompleted Rtheperr tbforomhundreddollars
($100)orlessJ WATDI HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
1 certify that N ma
the performance of the work for which this permit is Issued,
1 shall not employ any person in any manner w as to become subject to the WATER 5Y5EEM/TREAnN'G
Workers'Compensationlawsof GBfecnb. Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFI'. Date Recei t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Eaemption,you
F N should become object to the Workers'Compensation provisions of the Labor TOTAL:
Code,you must fort hwtd
ith comply with such provov or this permit shall W BUILDING EE
EL > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
EL Ihereby afRrmthat there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE Q7
_D Z ante of the work for which this permit b Indeed(Sec.3097,Cie.C.) PLUMBING FEE
O O Iender.Name
U. Lender.Address QTY. MECHANICAL PERMIT ITE MECHANICALFEE
U I ccrtifylhat l have read this application and date that the above information
O W escorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAI D:
} 1 relating to Wilding construction,and hereby authortee representatives ofthis
F N city to enter upon the abovementioned property for Wpeaken purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgment,cortsandespenseswhkh ayinanywayacave AIR HANDLING UNIT TTO I0,000CFM) SUBTOTAL:
agaieut. IdC immuesequenmo the grant Ng oft ) pemnIt.
AIRHANDLING IIM1TL(OVER 10,000CFM) CONSTRUCTION TAX
fIVITts' ure 9F App loot/ n<r o Date FXFIAIJSTFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
NA OUS MATERIALS DISC RE
Will the applicant or future building occupant storo adiehaearaom HEATING UNIT(TO 100,ODO BTU) Data Rece1 t#
materialasdeRned by the Cupertino MunicipalCode, aptcr9.12 and the
I Iahh and SafetyCede Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant Auto building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazan ous air contaminants as defined by the Bay Area Air /��RI�
Quality Ma nagement District? BOILER-COMP OFR'OR 10,000 BTU) PAID,FAIR
4I� Yen I❑�No
htvcreadthe hazardousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) OCT ) Q '{09(1
the California Health h Safety Code,Sectioua25505,25533 and 25534. 1 �Jha H U Is7 0
understa thatit thebuilding does not currently have a tenant,that it b my N•EWRESIDENIIALMECH. SQ.17
pass Itytonotifythe oc oto therequire nawhic mustbemet n.fi, as�/s�� s,/.�ss
P uanceota Ced i e I ancy Wv Vl E.."Pe14GI4V A
/o 9 V
Own or authorireda It
Dae TOTAL: ISSUED BY:
OFFICE COPY