21491 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMH'NO.
Baddlnda: s� 21491
surae n � vKQl1.D °"" CITY OFCUPERTINO-BUILDINGDIVISION vA
Contract a ame: _ Lce.No: APPLICATION / PERMIT' I I --.Z O 9 0
Lic.No: BUILDING-ELECTRICALPLUMBINGMECHANI AL CA RY CONTROL#
Architect/Engl r. �
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: P)RMITIS5UANCE Val ❑ 1-1 El
CONTRACTOR'S DECLARATION
I hereby affirm that l am ficensed under provisions of Cha pier 9(mmmon APFLIANCESRESTDENI7AL JOB DFSCRB'T'ION
Ing with Section 7(100)of Division 3 ofthe Business and ProfessionsCode,and my
license In full form and effect. PANELS
licnnaseCla . Lk.#
Date
Contractor UP TO 200ANIPS
ARCHITECTS DECLARATION 201-1000 AMPS
Rob I understand my plans shall be used as public records OVER 1000 AMPS SQ.Fr.FLOOR AR $/SQ.FI.
�d6
U Licensed Professional SIGNSELECTRICAL
<� OWNER-BUILDER DECLARATION SPLCIALCRCUIT/MISC
7 m(hereby affirm that l aexempt from the Contractors License Law for the
pp following reason.(Section 70115,Business and Professions Code:Any city or
O Z N u9 mpair TEMP.METER OR POLE INS('.
p� .3 any structure
requlmsa Issuance,
ssuan to alsore meas the
eapmvent for
ch,ormitt
g' .a any structure statemeprior to nt
that
he ise er and pursuant t the foroisiom of t e POWER DEVICES
ills a signed statement that he(Chapter Law 9(cod ening l it the tion 70ov of the
Contractors Lichnseand Preca9(mmmencing the he
xemptthe0%of Dinh SWN4MING POOL ELECTRIC
30�n sion3ofthe the
exemption. Any orlation Is exempt by any VALUATION O
a the bean for the alleged exemption. Any violation of Penalty
7o31S re any
{�55 as
applicant fora permit subjects theappltcanttoativll pemlry of sat more than OUTLETSSWITCIiESFI%TURFS •al-- O
C C it,,hundred dollars($500). NEW RFSIDENI.ALELECTR
I,as owner of the SQFL S[ORI TYPE CONSTRUCTION
7�n property, employees thelesole
C G mm(Sec.7on,wllldmhe ad Padvrk dthestructurche cmoact.enteaded or kens Law
d for
��❑ sale(Sec 7654,Bus4 ss and Professi°ro Code.The Contranols Urerue Taw '
$$ does not apply to an owner of property who builds or improves thereon,and OCCGROUP RDS.UNITS
whodoessuchwork himself orthrough his own employees,provided that such
Improvements are not intended proffered for sale.1(howeveq(hebuilding or TOTAL:
Improvement u sold within oneyearofcompletcon,the owner-bu0der will have
th rden of proving that he did not build or improve for purpose ofsale.). QTY PLUMBING PERMIT FEE FL00 W7 AAPN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to cosntrvct ec
the project(S .7014,Business and Professions Code:
no Contractors License Law does net apply to an owner d property who ALTER-DRAIN&VENT-WATER(FAT
Wild, or Improves thereon, and who contracts far such pojects with a
agaltactmW Bcenaed pursuant to the Contractor',License Law. FEE SUMMARY
LJ I am exempt under Sec. B h P C for this reason BACK l'/'7ROTECT.DEVICEOUTSIDE FELS
-
OTvn /a2 ' 1sR� Date n DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEII'1'N
KMAN COMPENSATION DELLA ATIOIT—N pa,Il1RFS ,I7LV' 1' Sp;OOL TA% Y N
oI here form that I have a artifWte of consent to elf-insure,ora RECEfIrf M
certificate of Wmkers'Comperuatican lasuranae ora certified mpythereof(Sec. GAS SYSITMII C PARK FEE Y N
MOD,Tab CJ
Policy k .. RECGIPI p
Com any GAS _.SYSTEM-OVER4(EA)
Certified copy 6 hereby furnished. BUILDING DI VISION IT ES
CertUod copy Is filed with the city inpectias division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(I'hissectionneed not bemmpined lftheperant laforose hundred dollars SEWER-SANITARY-STORM FA."FT. Date Recei t#
(41OD)aless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I snot shatIn othe person in
so as to bthis capemdtis issued,
I shall not employ any person in any manner m as m become subject to the WATER SYSTEM/TREA,IING
Workcri m
Compeatlon Laws of California. Date PAID '
O Z Applicant
Z O N'OTICETOAPPLICANT:E,after makingthis CertBlcate of Exemption,you NEWRESIDENTIALPLAB._SQA. Date Reed t#
sh°uld becom subject to the W°rkers'Compr ustlon provlslona of the Labor TOTAL:
LUH N Code,You mu a, arthwith complywRissuchprovisiomorthis permitshallbe
7 deomod revoked. BUILDING FEE _OD
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a corotructcon lending agency for the perform.
D Z anm of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
0O Lenders Name PLUMBING FEE
LLF LendndiAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythat]have read thbappliotionand Oatethattheabovecnformatim
0. Is correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authodm representatives ofthi,
Z city to enter upon the above-mentioned property for Impectcon purposes. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify an d keep harming,the City of Cupertino Date Receipt#
against liabilities,judgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(To 10,0DO CFM) SUBTOTAL•
aga Inst said City In consequence of the granting of this permit. -
,� '9d AIR HANDLING UNIT(OVER IO.ODOCFM) CONSTRUCTION TAX
Sigrutu Applicant/Contractor Date D(HAUSTHOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle harardoua HFA71NG UNIT(TO 100,000 BTU)
mmerlal as defined bythe Cupertino MuniclpalCode,Chapter9.12,and the _ Date RCC2i t#
IiOtYMd Safety Code,Setiion 2S532(a)7 HEATING UNIT(OVER 100,00D BTU) - TOTAL'
Will the applicant aro future building occupant use equipment ordevicas VENTILATIONFAN(SINGLE RESID) I U.Pt ,( •DATE
which emit harardoua air contaminants as defined byline Bay Area Air /"'aa�/
Q�alltY Mawgemnnt n�No F�TLER-MlMP
FW."
tI .)
4havereadthehaa gmterialsrequlremnnbunder Cha pier6.95of ��oyp � i990
EJ
the California Health6:SafetyCode,Sections 25505,25533 and 25535. Iunderstand that iftheWilding don not currently have a tenant,that lila my SQ.Fr. {sr as{ pmponsibility to notify the occupant of the requirements which must be metells VI NIIpB�I!IPprior to lssuarm of a Certificate ofOccupancy. V b SU'Owner or authorized agent Dae O\ v a'TAL: ISSUEDBY: P� C
OFFICE COPY
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