21791 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMHNO.
Building Address:
21791
ams. th A A
iO CITY OF CUPERTINO-BUILDING DIVISION
Cono-ator'a Nam: 11,1: APPLICATION I PERMIT 1'---)::)d-91
9401,10 BUILDING-ELECTRICAIlPLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: '3 �j �, t PERMITISSUANCE ❑ ❑
SED ❑
LICENCONTRACTOR' DECLARATION
I hemby affirmthat l amheensed under provblonsof Chapter9(commare APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 70DO)of Div sion3ofthe Busiressand ProfesslonaCcde,and my
license binfull fo—��d i.# 11II PANELS P I „ �1
License Class lf Liff c .�' J�O`4 O L��
Date I t�Contraaor me)
ARCHITECTS E —UP TO 200 AMPS
CLARATIO 201-1000 AMPS
ZOC I understand my plans shag be used as public records ENEWRFSIDENTIALELFCTR
O AMPS SQ.Fr.FLOOR AREA s/SQ.FT.
E Licensed Professlowi CTRICAL
�<6i OWNER-BUILDER DECLARATION IRCUIT/MLSC
Ihembyalfirmthatlamexempt fromthe Contractors License Lawforthe
qqqqqu� following mason.(Setion7QHS,Businessand Professions Code:Any city or
F Q3 countywhich requires a permit roconstrot,alter,hn TER OR POLE INST.
u� 3 prove,derrolbh,orrepair
nystructure ptorto its usuance,a6orequbes iheappllunt forsuch permitto EVICES
O file a signed statement that he 611rensed pursuant to the provisions of the O� Contrator'sLicense Law(Chapter9(commancing with Setion 70W)of Dlvl- GPOOL ELECTRIChe6 exempttFerefromandVALUATION
the basis for the alleged exemption. Any violation of Section 7(015 by any
applicant for a permit subjects theappllcint toa civil penaltyafnamerathan SWITCHESFIXIURFSlive hundred dollars E$SM.I,as owner o(the ro DENTIALELFCTR SQ.Fr,
�n ❑ p party,or my employees with Wages u their sole STORIES 7YPECONSMUCUON
comper sation,wW do the weak,and thestruture 6 not Intended or offered for
5 o sale(Sec.7044,Business and Profevlom Code:The Contractor's License law
S$ does extapply into owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
C• who does such work himself orthrough Ms own employees,providecithatsach
improveman6 arena intended oroffered for sale.It however thebullding or TOTAL:
improvement 6sold within one yearof complatlon,the owner-builderwill have
1 Nen of provingthat he did not build orlmprove for purpose of sale.). QTY, PLUMBING PERMIT FEE pLOOD7p qpN
Lj I,as owner of the property,am exclusively contr ng with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code: l
The Contractors License Law does not apply to as owner of property who ALTER-DRAIN k -WATER(EA
Wilds or Improves thereon,and who mmrats for auch ptojets with a (�
gR}(actor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
c 51 am exempt under Sec B N:P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date
' DRAINS FLOOR ROOF,AREA,GOND. 2 r� SANITARY Y— N_
. EPT N
WORKMAN COMPENSATION DECLARATION RC
❑I hereby affirm that I have a mtiBcete of consent to self-Insure,or a FIXTURF_S PER TRAP SCHOOL TAX K:--LN
certificate of Workers Compensation Insurance ora certified copy thereof(Sec. RECEIPT N
3800,Isis C.) ('') pp LI Q GAS EA.SYSTEM-1 OUTLEFS PARK FEE Y N
1'oliry N `Ci qct
1 1 RECEIPT N
Com any_ s. -by v� R1_L�-tJ GAS FA.SYSTEM-OVER BUILDING DIVISION FEES
OCetlfled copy 6 hambyth the city tf '-1
❑Cetlfed copy 6filed with the ttylnspetion division. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHL-CK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID-
(This
COMPENSATION INSURANCE
(This section need net becompieted it the permit 6 for one hundred dollars SEWER-SAMTARY-STORM F.A.200ET. Date Recei t#
(aI I cardless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ces t employ
n any person
in any
the work so as in b this pesubjecrmit is iso therd, —
1 shat not employ any person In any manner at ss to become subject to the
Worken'Compensation lawns of Calitomla. Data
WATER SYSTEM/TREATING
O Z Applicant PAID
Z O NOTICE TO APPLICANT-.If,after making thC.C.tffrle of Exemption,you NEW RESIDENTIAL PLMB._SQFT, Date Remi t#
Fshould become subject to the Workers'Compensation pmvlshms of the Labor
W Code,you most fan hwith comply with such provlslom m
or this pedt shall be TOTAL:
LU > daamed revoked. B ILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafffrenthet there construction lenciingagenry,forthe perform
7 Z ance of the work for which this permit 6 Issued(Sec.3 ,Civ.C.) TOTAL ELECTRIC FEE
V O <ndars Name PLUMBING FEE
IL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cetdythat l have read thW pph-tinnandstatethattheabovelnformation
LL scorret.I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
} N relating tobulldingmmtrutioq and herebyauthotva representativesofthis
F Z city to enter upon the abovamentioned property for Inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless
the City of CuPari Date Receipt#
agaWtllablWies,pdgnenb,cotsand expenaeswhich mayinanywayactue AIR HANDLING UNIT(ED 10,000 GEM) SUBTOTAL,
agalnt said City m cons of the gr nil Of pesnit.
AIR HANDLING UNIT(OVER 10,000CpSD CONSTRUCTION TAX
slSn"
of plcant/Comra or `Date IXFIAUSCHOOD(W/DIKE) CONSTRUCTION TAX PAID:
HA2A RDOUS MATERIALS SCLOSURE
Willth (cantorfuture building occupant store or handle hazardous HEATING UNIT(TO IWWO BTU)
material as defined by the Cupertino Municipal CodeChapter 9.12 and the Date Recej t#
,Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,OW BTU)
F-1yes NN. TOTAL:
Will the applicant orfuture building occupant use equipment or devices VEN'IIIATION IAN(SINGLE RESID) ISSUANCE DATE
which emit hannious air contamimnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) PAM
�- Ycs ❑Notercr1 M
4have read the h &Safety
Code,b mons 255 requirements 5533 an M1apter 6.95 of BO GR-COMP(OVER100,000 BTU) �/J� a i
the nrnis HealthbSafety Code,net
nsntly have
a tenant,
d2that it n 7t
understand that if the occupant
na currently haves hick that it met NEW RESIDENTIAL MEQi. SQ.FT.
responsibilityce of aCthe occupy nt cthe requirements which must be met
prior to Lssuance of a Certificate of Occupancy.
Owner or authorised agent Data
IOTA L: ISSUED BY:
OFFICE COPY