21388 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
B0;?–' q i ��V�
uilding Address:/ h PERMIT N21388
S
vj one: A A I tL N AD 9 CITY OF CUPERTINO-BUILDING DIVISION p
Contractors Name: LIc.No: APPLICATION / PERMIT
Architect/Engineer. Lic No. BUILDING-aECTWCALPLUMBINGMECHANICAL CAIICARY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMI7155UANCE �C–fl ❑ ❑ ❑
UC ENSEDCON------under rDECLARATION �f
I hercbyion 700that 0M iv Beamed underprov6bnsofChapter9(commme APPLIANCESRESIDENI7AL JOB DESCHII'1TON
1ngweh5ectbn to.anDivWon3 ofthe Bupmdaand PsofesslomCarde,and m
license Is In s fors and C 11 PANELS ^ 0
License Class—LIC 11 �J
Date Contactor —UPT02DOA 'S
ARCHITECTS DECLARATION 201-1000AMPS
rep 7O I understand my phm shall W used as public records. OVER 1000 AMPS SQ.IT.FLOOR AREA E/SQ.FT.
ZLicensed Professional SIGNS ELECTRICAL
«<� )d OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
7p, , Ihercby affirm that l am exempt from the Contractor's License Law for the
Ofollowing reason.(Section 703 1.5,Business and Professions Code:Any city or
F f'u9 counlywhichrequiresapermittocomtm0,alter,improve,denol6h,ormpalr TEMP.METER OR POLE INST.
any structure prior to its Issuance,also requires the applicant for such permit to
file a signed statement that he la licensed pursuant to the provisions of the POWER DEVICES
w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
O sion3ofthe Bupnessand ProfeabnsCde)orthahe6exempttherefmmand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any �Q x
n applicanlfora permit subjects the applicant loo civil penalty efna nom than OUTLEISSWHCHESFlXTURES O
flue hundred dollars hefo . NEW RESIDENTIAL ELECTR
❑I,as owner of theproperty,or my employees with wages r fferdole SFT STOW6 TlT'E CONSIRUCTIOK
C ¢ coopensat0KBuldo the essandrk.andtheprocture,is e:TheC Contraintenctors
5 ed for
sae(Sec apply to Business and f property Code The Contractors Lioeme law
j$$
who ddoes oes
apply roan owner ofpropertywho Wilds
mporimprovnted that such
0. whodoementswork Mmself tended hrwghhis own ale..ItywnervWeuildinuch OCC.GROUP RF5.I1NTT5
Improvementsarenot Intended earofcedfarsale.ILh er-g Uder ilingor TOTAL:
Improvement 6soldwithinoneyearo(complctbgtheowner-bu0derwlllisave
I comfEenceingthat he did nmbuRdorimproveforparpoxofse1c). QTY. PLUMBING PERMIT FEE FL ,mNE KpN
L a owner of the property,am exclusively contracting with licensed pFRMTT]SSUANCE
nta ra to construct the project(Sec.7W4,Business and Professloru Code:
Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT- (EA)
Wilda or improves thereon, and who contracts for such projects with a WATER
coiVetor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L_J I am exempt under Sec. B&P C for this reason BACKFLOW PROTECT.DEVICE
Owner to DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEn
C31 hereby affirm that I have a certlf oam of consent to self-Insure,or a FIXTURES.PER TRAP SCI 1001,TAX Y N
cm9ficate of WOrkers Compensation Insurance ora certified copy thereof(Sec. RECEIPT#
3800,Lab GAS FA.SYS7EM.I INCA OUTLETS PARK FEE Y N
Polley# RECEBxf#
Com any GAS EA.SYSfFM-OVER#(FA) BUILDINGDIVISIONFEES
�Cnatfied copy is hereby fumlahed.
C3Cenified copy b filed with tM city Inspection division. GREASEANDUSiRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhlasetionned not becompled lithe permit 6forom hundred dollars SEWER-SANITARY-SHAM EA.HAFT. Date Remi t#
(81p0)arlesh) ENERGY FEE Y N
I ll not that In the any person
in any ibe w.1manner brwhicb thispermit Is
subjec Issued, WATER HEATER W/VEM/ELECTR
I shall not employ any person In any manner o u to become object to the
WorkersCompensationompensation laws of Gh(Orn6. Date WATER SYSTEM/TREA7Ih:G PAID
Z Q NOTICE TO APPLICANT:If,after making thisCertificate Of Exemptlon,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Remi t#
should become subject to the Worken'Compemation prov6lonsof the Labor
W~ N Code,you must forthwith comply with such provisions orthis permit shall be TOTAL:
> dermad mvokd. BUILDING FEE 3.OB
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE t
= Z I hereby afRnv that there 6.mmtruction lending agency for perform .TOTAL: ELECTRIC FEE
O ance of the work for which this permit 6 Wud(Sen.3097,Civ.C.)
V Lendee.Name
Adde PLUMBING FEE
Ly k nder.AddreIs QTY. MECHANICAL PERMIT FEE
O W Icertlfythatlhavereadth6 applistlonandpatethanheaboveinformation MECHANICAL FEE
IL 6correct.Iegreeto comply with all city county oNinancesand pate laws PQLMTT155UANCE FEES PAID:
} relating to building construction,and hereby authorize reprexntatives 0f this
F Z city to enter upon the above-mentioned property fee inspection pu rposes. ALTERORADD'PDMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,jsdgments,cops and expenses which may in anyway accrue AIR HANDLING UNIT 10,"CFM) —SUBTOTAL:
ago Inst said City in consequence of the grant Ing of this pe t.
�� `,— — �'//S/g AIR HANDLINGUNIT(OVERI0,awCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor :bythe
Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERISCLOSURE
Will the applicant or future building ocstore or handle hazardous HEATING UNIT 100,000 BTU
nuterialis defind by the Cupertino Munode,Chapter 9.12,and the ) Date . -Recei t#
I fralth and Srfctycde Section 25532(a)tHEATING UNIT 100,000 BTU) rjfi'�° TOTAL- x�
❑Yea Q No
Will the applicant Or(uturebulldingocuse equipment or devices VFNIILg7ION FAN(SINGLE RESID) 1(av�C4'E(DIA•FE
whlch emit ha ardous air-ruminants as by the Bay Area Air py U $UA
Qu lilyManagementD6Mct7 BOILER-COMP OHP OR IOQIX0 BTU) 1 u❑Yca ❑NoIhavc read thebuardous materials reqnts under Chapter6.95a( ROLLER-COMP(OVPRiW,Ofp BiU)the Glifrnia Health&Safety Code,Sectio5,25533 and 2553p. I understand that if the building does not cuhave a tenant,that it 6 my NEW RESIDENTIAL MECH. SQFf,responsibility to notify the occupant of thements which must be metprior tis issuance of a Certificate of Occupa _
Owner or authodud agent Date
TOTAL: ISSUEDBY:
OFFICE COPY