21259 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
G 21259
22x93 (NCbpr?,�4b
Mra inC, one: APPLICATION SUBMI
A
_,4 Q -4049 CITY OF CUPERTINOBUILDING DIVISION
CMm :6SPaa Lie,N.: APPLICATION / PERMIT
O O
YAWdFWPL!ES
C16r Agzzy BUILDINGELECTTUCAGPLUMBING-MECHANICAL CAT AWRY CONy!{
Architect/Engineer. Lie.Nex b/�
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO— /
Address: - PERMIT ISSUANCE ` —)1 X
LICENSED CONTRACTOR'S DECLARATION 1,4
Iherebyaffrmthat l am licensed under provisions a(Chapter9(mmmenc APPLIANCESRESIDENTAL JOB DFSCRU'DON
ingwlth Section 7000)Of Divisian3ofthe Buslneuand Pmfession.Code,and my
Iicena is in full,fQrcg and effect Z_':Zl •tL� PANELS
Limn CIaeS�Lk.p .i_7�1g / (�ytT
Da(e Contractor L\
ARCHITECT'S DECLARATION 201-1000 AMPS
077 lunderstandmyplamah UbeuwdmpubBcremrdw OVER1000AMP3 SQ.FT.FLOOR AREA $/
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER� DECLARATION n SPECIALCE(CUIT/MISC
z p,ul I hereby axon. that(ect I am exempt tromthe d Professions
s icenseCode:Lw for the
(o8owing reason.(Seaton 78115,Buslnea and I'ro(eahans Code:Any tlty or
O t:.� TEMP METIER OR POLE INST.
�� countywhich requlrcva permit toconstmct,ilter,lmprove,dennlleh,orrepalr ,
g anyarncture pnorto its Issuance,also requireatheappllcant forsuch permit to POWER DEVICES
L5 O file a signed statement that he Is licensed pursuant to the provisions of the
06 Contractor's License law(Chapter 9(commencing with Section 7000)of Dlvl-
T,3p than Iofthe Business and Professions Code)or that he is exempt therefrom and SWIMMING POOL ELECCRIC /� VALUATION
6 the Iasis for the alleged exemption. Any violation of Section 7831.5 by any
nt0 OUTLEISSMTCHFS-FIXTURES 19.I rQ0 O
applicant fora permit subjesthe applicant to a civil penalty of not morethan W
five hundred dollars($500). NEW RESIDENTIAL.ELECTR�_SQ.FT. STORIES TYPE CONSTRUCTION
�j.. ❑I,as owner of the property,or my employees with wages an their sole
rompeneatlon,will do the work and the structure v not Intended or offered for
Cl ask(Sec.7064,Business and Professions Code:The Contractors Limns,Law
�_I$$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUT' RES.UNITS
E4: whodoessuchworkhlmselforlhr ghhisownemployees,provldedthatsuch
improvements are not Intended orotfered for sale.If,however,the building or TOTAL: ks�CJ
Improvement Issold within one yearof completion,the mvner-bullderwill have
tlXjZurden of proving that he did not W lld or improve for purposs of sale.). QTY. PLUMBIN PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed 1 PERMIT ISSUANCE
contractors to construct the project(Sec.7074,Business and Profeaiom Code: 1
The Contractors License Law don not apply to an owner of property who pLTERA VLNT-
Wilds or Improves thereon, and who moments for such prokas with a (�
oq➢tT�aorWuanwd pursuant to the Contetlor.License Law. BACKFLOW OTUT FEE SUMMARY
LJ I int exempt under Sea 8&P C for this reason
DRAINS FLOG ND. SANITARY Y N
1 OUTSIDE FEES
Owner Dam RECEIPT$
WORKMAN COMPENSATION DECLARATION FIX.I.URFS.I SCI100L TAX Y N
1 hereby affirm that I have•mrti8cate of consent to selbineure,ora RECEIPT M
cele,,,cate of Works.'Compomatlonlmumnmoramnitied mpythereof(Sec. CAS EA. NC.40 PARK FEE Y N
3800,lab C.7
Policy# r*a — RECEIPTS
Cam any GAS.EA ER41 ) BUILDING DIVISION FEES
�Cenlfle copy Is hereby furnished. GREASE/ND STR sops P[.ANCFIGCK PEE
Certified ropy V filed with the city Inspection division. s �-@�¢�
CERTIFICATE OF EXEMPTION FROMWORKERS' GREASE pAIDI6� 0 �
COMPENSATION INSURANCE SEWGR-SANITARY 20.IFr Date Race! t# {831
(This tectlon need not be completed if the permit le forone hundred dollars
($100)orlcWATER HEATER W/ TR ENERGY FEE Y N
Icenityththat in the performance of the work(arwhlch this permit is issued,
I shall not employ any person In any manner so u to become subject to the WATER SYSTEM/TREA NG
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW R[SIDENTTAL B. SOFT. Date Recei t#
Z O NOTICE TO APPLICANT.-If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation prev4lons of the Labor TOTAL:
N Code,you most forthwith comply with such provislons or this permit shall be U NG
W deemed revoked.
LU G CONSTRUCTION LENDING AGENCY SEISMIC F ZZ
Z Ihembyafflrmthatlhere isamnstmalon lending agency for the perforrm TOTAL: ,y ELECTRIC FEE� ncx.fthrw.rkforwhiehtld.pe mdtlsisurd(Sec.3097,CW.COV O Landers Name R`� PLUMBING FEELL Under.Address QTY. MECHANICAL PERMIT FEMECHANICAL FEEOW Imftlfythatl have read thinapplicationand date thatthe above information �Y aayye�
d. ucorrect,I agreelo complywith all city and county ordinances and state laws ` PERMITISSUANCE I LtLa� FEES PAID:
} relating to building construction,and hereby authorize representatives of this
F city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMFTH.
Z (We)agree to ave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
again IJ bill I jadgrrenb,costsand ex cies which may lnanywayacaue AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
agai raid Citylncons c...fth a in ofthI.permlt. '
0� AIR HANDLING UNIT(OVER 10,ODOCIM) CONSTRUCTION TAX
Slg tdfhc of Applicant/Contractor Datc EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applica ntorfuture building aavPant store or handle hazardous HEATING UNIT(70100,000 BTU) Date RCCCI t#
material as defined by the Cupentina Munitlpal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(02 HEATING UNIT(OVER 100,OW BTI!) TOTAL:
nYea No '
Will the applicant oehiture building occupant use equipment or devices VENTILATION FAN(SINGLE RESIU) ISDATE
which emit havardom air contaminants as defined by the Bay Area Alr
Qua tlty Ma nagament District? BOILER-ODMP OFR'OR l00,OfO BTLft
Yea qNo V•�
hevereadthebaza ossa ma terlalsequiemnntsunderChaplerb.95of BOILER-COMP(OVER 100 00 BTU) - On�
the Gllfomle Health&Safety Code,Sections 25585,25533 and 25534.1 VO
understand that It the building does not currently haves tenant,that ltBmy NEWRESIDEhMALMECH. SQ.FT /K
reeporu Ility to not lty the oaupanmo requircmentswhich must he met %VS
pno uance of a CediOcateof0 p
Owner dr author zed.8a.1 Data TOTAL: ISSUEDBY��:: �� W
OFFICE COPY