21526 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALL POINT PEN ONLY
Building Protect ldentllintlon PERMIT NO.
Building Address:
21526
AV
n one:
. '/I/�/ A i C F CITY OF CUPERTINO-BUILDING DIVISION
ContraTp➢arhe;F Lk.No: - APPLICATION /PERMIT
C (I�— BUILDING-ELECMCA�PLUMBINC-MECHAMCAL CATEGORY - CONTROL#
Architect/En neL Lk.No:
/ �1 a� QT,Y ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Adder' : 2036 CL A- -Sl- 0171317 tcncl MUMS MTrFT
PERMIT ISSUANCE �Z.cro ❑ _ � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION '
thereby affirrothat l am Ilcensed under provbionsofChapter9(commeno. APPLIANCESRESIDEM7ALingwitJOB DESCRIPTION
hextush ].full force and flec n3o(the BugnefeandProfesgonsCode,and my
Liomsle I.full force and e.# PANELS "
Lkenw Clam LIC.R ,
Date .Contractor UP TO 2DOAMPS '
ARCHITECTS DECLARATION 201-1000 AMPS
90W z I understand myplaro shag be used as public records OVER1000AMPS t , SQ.FT.FLOOR AREA $/SQ.FT.
��yyy Licensed Professional SIGNSELECTRICAL
4 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C SO 1
7 a Ihereby affirm that l am exempt from the Contractors License law for the L
pp O
Following....(Sceion70315,Business and Professions Code:Any city or y e,
F � cwntywhlch requlrnapermitbmrietsuct,alter,(mpmve,demolish,orrepalr TEMP.METERORPOLEINST.
anystmcture priecto itsiemance,also requireatheapplicaut frrsuch permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
w Contratmre License Law(Chapter 9(commencing with Section 7000)ofDivi-
110E-e sion3ofthe Buslneeaand Pro(essioroCWe)orthathebeminptthemfmmand SWIMMING POOL ELECT RIC VALUATION
the basis for the alleged exemption. Any violation of Section 70015 by any
G applicant fora permit subjecothe applicant to a civil penalty of net ore than Ol1TLETSSWITCIiESFIXTURES
room
ftyeyuns ed Owner
rlof hepr. NEW RESIDENTIAL ELECTR
11�nQ 7,as owner's the property,or my employees with wages as their cols STORIES Ttt'E CONSTRUCTION
c pemation,will do the work and the structure V not intended or offered for
Ois(Sec 7044,Business and Professions Code:The Contractor's License Law
$ does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP RFS.UNITS
who doeaeuch work himself ortM1mugh his own employees,provided that such
Improvements are not Intended oroffered forsale.If,howevepthebuildingor CA
7pL;
improvement bsofd within oneyearofcompletion,the owner-buiklerwiil have
t)t*rden of proving that he did notbuild orlmprove for purpose ofsale.). QTY; PLUMBIN M I FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PQtMTC ONCE
T atractOn to construct the projed(Sec.7044,Business and Professions Cade:
The Contndor'e License Law don not apply to an owner of property who �.�D & p ffFN
builds or improve thereon,and who connacta for such pru)eds with a FEE SUMMARY
c t.[edor(a)Iimnwdpumantwthe CmtmdoaLimnm Law. lipCK FLOW DEVICE
1_11 amsunder Sec. B,&P C for thin reason
r\ OUTSIDE FEES
DRAINS R F,AREA, SANITARY Y N
Owner - Date RRCERrT p
WORKMAN COMPENSATION DECLARATION FDHURES PER SCHOOL TAX Y N
❑I hereby affirm that I have o wrtigcale of consent to self-insure,ora RECEI'T M
certificate of Worken'CompeasaHon insurance oracertlfled copythereo((Sw. CAS F.A.SYSTEM-t INC.40UTL PARK FEE Y N
Policy
lab C.)
Polley paDECEIT p
CaMCny GAS EA.SYSTEM-OVER 4(EA) BUILDING DIV
ISION FEES
ertNed
copy is hereby furnished.city
MCegi(led copy b(find with the city inspection division. GREASE/INDUSTRL WASE INTEItCkTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM FA.200FT. ,Date Recei tN
(fMawction need sat be completed If the permit b(Drone hundred dollars
($1I0)orfeen.) - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertlfy[hat lnlhe pedomance of thework lorwhich Wepermit bissued,
I shag not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
ApplicaO 2 NOTICE NEW RESIDENTIAL PLMR. '9QFr. Date Recei t#
Z 0 NOTICEco become subject
orkerakinglhbsation Certificates Exemption,you
should you=at fort T to the W ly.wit Cuch provisions
n provisions,per it s Labor - TOTAL:
LU N dnoved revoked.forthwith comply wish each proWlov orthb permit shall be BU .
IL G deemed revoked..
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
]hereby af(irmthatthere isammtmctlon lending agency(orthe perform . TOTAL: ELECTRIC FEE
L) Z ance ofthe work for which this permit is Issued(Sce,3097,Civ.C.)
U O Lender's Name PLUMBING FEE '
LL F- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 certilythai l have read this applicationand statethattheabove ln(omuHon
.a bcorred.I agrcetocomplywith all dtyand countyordinancesand gate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and herebyauthorize represenhtivesofthis
(_ Z city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MECH. Date RCCelpt((
— (We)agree to save,Indemnity and harmless the City of Cupertino
agaim IlabigHes,judgments,m��((qq arR�dd meswhichmzylnanywayaceme AIR HANDLING UNIT(TO 10,ODOCFM) SUBTOTAL:
ago as City In caneequeaRkdf 4fiee a to of his pem it.
AIR HANDLING Dn1T(OVER lolwo cF'M), CONSTRUCTION TAX
Signaturi,x.fAppliant/Contractor Data E)(HAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI It{
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 RTU) TOTAL: I q370
❑Yea '
Willthe applicant oi]No
rfuture building oavpant use equipment or devices VENTRATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? - BOILER-COMP QFm OR 100,000 BTU) J
Yea nnNo Pt'�n
have read the hazarMous materialsrequlrcmentsunderChapter6.95 of BOILER-comp t00,OW BTU) H-O��
\ the Califirmi.Health&Safely Code,Sections 75505,25533 and 25534.1 - h
understand that if the building don not mrrently have a tenant,that it is my NEW RESIDENTIAL MECH. 9Q.FT. �)"j N, IPA
responsibility to notify the occupant of the requirements which must be met }•�'+1jdFw(i
prior to issuance of a Certificate ofOccu Fancy.
\ Owner or authorized agent - Date
ISSUED
TOTAL: BYV2-yC'
- OFFICE COPY