21367 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemificstion PERMIT NO.
8ullding Add�,o��. Q, 21367
77w.—M. ams: one:
CITY OFCUPERTINO-BUILDING DIVISION
Contractor's Name�� Lie.No: APPLICATION I PERMIT L
BUILDING-ELECTRICAIFLUMBINGMECHAMCAL CATEGORY CONTROI/M
Arch[ Fsglnee. iP is 10 LbtO
�lll QTY ELECTRIC PERMIT PEE BUILDING
/PERMIT INFO
Add . a WlAr PERMETISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DB RATION �I
I hereby affirm that l ern licensed under prwWons of Chapter 9(mmmenc APPLIANCES-RESIDENTIAL )IQ{i DESCRBrfION
Ing with Section 7DOO)of Division 3 ofthe Bus!nese and ProfeasionsCode,and my
Bcxnse is in full(arm and effe<I. PANELS /
License Class Con
Date Contnctor C/
ARCHITECT'S DECLARATION 201-1000 AMPS
q�q�+ur
90 O I understand my plans slu i be used as public records. OVER]ODD AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
k I=j Licensed Professional ISIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Ihereby affirm that[am exempt fmm the Contractor's License Law for the
following reason.(Section 70ILS,Business and Professions Code:Any city or
Fr TEMP.METER OR POLE INST.
,a county which requirma permit to construct,alter,improve,demelish,orrepair
anystmdumpriortolbbwancGalsorequimotheapplinntforaochpermtto POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
0 Contractor's License Law(Cha Fier 9(rommencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
eion3 of the Butlness end Professions fessns Cade)or that he is exempt therefrom and VALUATION
S the basis for the alleged exemption. Any violation of Section 70315 by any 6 OUTLETSSWHCHMFIXTIIRES
oapphmnt fora permit subjects the applk nt to a civil pointy of nut mem than (,five hundred dollars($500).
ni,as owner of the property,or my employers with wages as their sole NEW RESIDENTIAL ELECTR SQ,Fr. STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for f fA
Osale(Sec.70K BuWess and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improve thereon,and OCC.GROUP RFS.UNITS -
who does suchworkhiresetforthrough his awn employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement b sold within one yearofcompletion,the owner-buliderwill have
t4ttfurden of proving that he did net build or Improve for purpose ofsale.). QTY. PL BING PE IT FEE FLOOD LONE APN
u L as owner of the property,am exclusively a ntvcting with licensed
contractor to construct the project(Sec.70K Business and Professions Code: 65ACK
E
The Contrsaorb License law don not apply to an owner of property who I WA ffA)
Wilds or Improves thereon,and who contracts for such p(ojeas with a FEE SUMMARY
�gB.t don.)Iteensed pursuant to the Contractor's License Law. T.DIJ 1 am exempt under Sec. B&P C for this reasonOUTSIDE FEESOwner Date ROOF, ND. SANITARY Y NRECEBT MWORKMAN COMPENSATION DECLARATION❑I hereby affirm that I have a certl0cate of consent to self-InsuTw`P SCHOOL TAX Y_ NRECEPT NherePARK FEE Y N31100,Lab C.) -
Policy M RECEIPT a
.SYSTEM-OVER4
Co ny BUILDING DIVISION FEES
eniftedropybiumbyfumished. SE/IVDU WA TOR PLANCIiECIC FEE
Cchilled copy b filed with the city Inspection division. T-�3 pr
CERTIFICATE OF EXEMPTION FROM WORKERS' G PAIDI O 7D�C�1
COMPENSATION INSURANCE SEWER-SA Y- EA.200117. Date RelYa [M
(Thissection need not be completed if the permit b forone hundred dollars
(RalEmless.) WATER HEATER W/VENT/ELECTR E•NERGYFEE Y N
I certify that In the pehorrtunce o([hework(orw0ch thle permit le Issued,
I shall not employ any person in any manner n u to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei tri
_Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provision of the Labor TOTAL:
H N Code,you must fen hwilh comply with such provisions or this permit a hail be
W > deemed revoked. BUILDING FEE
s
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE 2
I hereby,&Emnthat there b ammmuction lendingagency forthe perform- TOTAL: ELECTRIC FEE
D Z once ofthe workfor which this permit is issued(Sec.3097,CIv.C.)
U O Lander.Name PLUMBING FEE
F ]anda'.Address QTY. MECHANICAL PERMIT FEE
LL U Imetllythatl have read thbapplicalonand statethat thesbove informal. MECHANICALFEE
O W is correct.I agreetoco with all city and county ordinances and nate laws PERMITISSUANCE FEES PAID:
} C relatingtobuildin rut aion,andherebyauthoh mpre nUtivnofthis
(.- N citymenteru thea, emetlonedproperty for ins salon sea. ALTMORADDTOMECH.
? No)a sav demrdfyand keep a h I Cupertino Date Receipt#
V agaln,tllab 1 gerants,. .:n Pa is i ways.. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaWt tyimm.sequen oft egoit P
s AIR HANDLING UNIT(OVER I0000CFM) CONSTRUCTION TAX
aesagn rcofAppliant/Contractor me EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: -
HAZARDOUSM ERIALSDIS OSURE
Will the applicant or future building occupant at orlundlehazardous HEATING UNIT CEO 100,00 BTU) Date Raei tp
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
a and SafetyC on 2S532(a)2 - HEATING UNIT(OVER 100,000 BTU) TOTAL:
'o apph.M3 building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
hichemithaaardou, rontaMna/nL'i�as deBo¢d�(y�y bell It BORER-COMP OFSI'OR l00,IX0 BTU)
O nuithchgo tD�7 Vl��v7� �S�
e9 IN
have read theft smatecials requirements under Chapter o BOILER-COMP(OVER 100,000 BTU)
the Callfomla alth& lay Code,Sections 25505,25533 and 3C I x
understand at fthe bulldingdoc.run re y v tuna ,thatitbmy, NEW RESIDENTIAL MECH. SQ.FT
responsibl' t oily the uccupan t Ire m.w must be rnM 'K v
prior to a ofa Ccrtl(Ic of ncy. / '
( ael-
ce Pj t�
thahzad agent Data TOTAL: ISSUEDB :
J
OFFICE COPY