21034 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PMMITNO.
Building Address:.
21034/o .
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neraTL�G(J T �• �rV NL VALE
PD e CITY OF CUPERTINO-BUILDING DIVISION Q^(�C�Q -APPLICATION A.
C ntactor'aName: L o: APPLICATION / PERMIT
Architect/Engineer. Lle N. BUILDINGS,ECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL g
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PPRMITISSUANCE I2(X El 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afiren that l am licensed under provWons of Chapterl?(commerso APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth SecHon700o)ofDWINon3ofthe BuNawand PmfessloneCode,andm -
license is In full to.and effect, PANELS
License Claw ic.0
Dale Contractor UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1000AMP5
Z I understand my plans shall be used as public records OVER1000AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
�{q❑u CO
6 b(� Licensed professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC L CQ
I hereby affirm that l amexempt fromthe Contradoes LicenseLaw fo the
2p following reason.(Section 7MIS,Businessand Professions Code:Any a ty or r
O Z i. ir TEMP.METER ORPOLE WST.
P
county requlnreapermkto alsore uireatheapmvgde rsuch rmit to
g� anynacturc prlorto lbtaaae,aiso requlreslheappBmaht(oauU(permit to POWER D� W
[`J�w file a signed statement that he b licenced pursuant to the P vi I r�i of]the a_
3 u'1n Contractor's Liceve Law(Chapter9(commen.g wllh Section70�of unci' SWIMMING POOL ELECTRIC VALUATION
�0� Non3ofthe Budnessand ProfemioaCode)lulatinrd See 'th31_5by any
the beat fur
,,,alleged exemption. Any violation of Sed�7Bt ro by any oVILE FIXTURES
6� aPPBcant Jura permit S""I theapplicant tea dull penaky Wnat nnre than -� t
r
dred dollan'spr. a / NEW RESIDFMIAL ELECTR SQ.FT. STOWFS TYPE CONSTRICTION
aowneo!thepropsrtNyyormyemployeeswithwagesas their sole7aadon,will do the work.'Sndthe structure is not ttended or offered for`t� 7094Buabess and Prd(esllons Code:The ConraLuise I"
UP2 apply to an.ward pigpertywho builds."Improv.thxrvmr'and _ OCC.GROUP RES.UNITS
EE who done itch workhlmseBertheough his own employe Jmxulded thateuch r- �1
Improvement are not istended oiroflered for eale;af,'howevep thebulldingo TOTAL: a
Imp"wementteoId wlthlnoreyeat.complNlorytheawner-bulldy''rwWhave
tlR,turden ower of that he did rad hu lldorlmprove for purpra .fejt.). TY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lf I,as owner of the property,am_lost sly wnt_i.a wltlJto Ili4need
con.ctow to coawct the P. (See 7091,Bualnew and Profess .Code PERMIT ISSUANCE
The Contractors Llcense Law does not apply to an owner of property who ALTER-DRAW k VENT-WATER BA)
Wt, ser Improv.thereon,and who contra.for such plmjeda wish a FEE SUMMARY
cgelTecior(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B h P C for this reason
OUTS]DE FE E 5
DRAINS FLOOR,ROOF,ARRA.COND. SANITARY Y N
Owner DataftECEIT M
WORKMAN COMPENSATION DECLARATION FIXTURES,PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have•certificate of consent to sal(-Insure,ora RECEIPT M
certificate cfWorkers'Compensation lnsurencemra certified copy thereof(Sec. GAS PA.SYSTEM•]INC40U�TLETS PARK FFR Y - N
3800,Lab CJ RECEIPT_
Policy
CffCanGASPA.SYSITMAVU 4(FA)
BUILDING DIVISION FEES
crtfied
ropy is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' I GREASE TRAP PAID
CAMPENSATION INSURANCE - SEWER•SAMTARY STORM EA 200Fr Date Recei [#
(Thlssection need not becompleted lithe permit b forone hundred dollars
($100)orless.), WATER BEATER W/VENT/ELECTR ENERGY FEE Y N
cerma
I tlfythat in the performance of the work for which this permit is bound,
1 shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQbT, Date Recei t#
Z NOTICETO APPLICANT:If,after makdng thin Certificate of Exemption,you
should become subject to the Workers'Compensation provisions mf the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthb permit shall be BUILDIN
G FEE
LU j deemed revoked.
IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a mwtruciton lending agency for the perfomry TOTAL: ELECTRIC FEE
7 O arm of the workfor which this permit b issued(Sec.3097,Civ.C.)
(� Lenders Name PLUMBING FEE
LL LandersAddreas QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
O O Iurtifythatl have read thisappliatbnaod nate that theabove Infrma
otion
1 bconed.I dgreeto comply with all cityand county ordinance and Nate laws PERMITISSUANCE FEES PAID:
relating to building construction,and hereby authorisese .
reprentatlyof this
N
[_ city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH. -
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recei [#
V pagmt
Wlies,ludgment,"sand expenses which may In anywayaceue AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
City in con em.of the grant his permit. / ,URL{ANDLINc urarr rovFR lo,133o cFnDCONSTRUCTION TAX
Apt Ilcant/ContractorDate EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCUD RE
Will the applicant ce future building onupnt store handle hazardous HEATINGUMT(TO100,0008U) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety C a Ion 25532(a)1 HEATING UNIT(OVER 100,000 BTUs TOTAL: k—L O
❑ Yce o
Will the applicant oullubire building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUANCE D
which emit hazardous air contmW ms as dellned by the Bay Area Air
Quality Management Di trid7 BOILER-COMP OH POR 100,000 BTU)
4 Y. q
haveread thefts_ ousmuteelatrequ 25505,sundeand 2SS3r G95 of BORER-COMP(OVER 100,000 BTU) SLP 1
theCalifornia Health& fety Code,Scd1oantly have
a Leant that it
reapostandthm if the notify
Ceding does of to currently haves tenant that it met NEW RESIDENTIAL MCCdi. SQFT.
responsib0tty to o,ofatdtfica I of lherequlrementswhich mustbemei city of Cu rs_a
pdo arm ala Certlfica cos panty. SjflaZl��.R,@�.Fi1�1m�f1)/1
mer r uthorizad agent Date - O TOTAL: ISSUEDBY: "`"�" I•'Iwd w"lYa�a
OFFICE COPY