21351 (2)•
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMITNO.
21351
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUH.DINGELFCTRICALPLUMBING-MFCH LAICAL
APPLICArUNTUMMITAM A
y
G°^t a �Q+9
CATEGORY
CONTROL #
Architect/Ggineer. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMITINFO
Address:
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACEOR'S DECLARATION
Iherebyaffirm that l am licensed under provisions of Chapter9(commenc
'ngw+th Sect(on700Bof Divbion3 ofthe Businessand PrefesslonsCode,and my
license is Infull o deffect
o e^ as" CoLicn mrto ° 9 a� �y
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby of — that Ison exempt from the Contractor's License lawforthe
following .... (Section 7031.5, Business and Professions Code: Any city or
c ntywhichmquiresapermittommtmct,altegimpmve,de=lB h,orrepair
anysrructure pdorm+ts issuance, elan requiresthe applicant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(mmmencing wish Section 7000) of Divi-
slon3ofthe Bualnessavd Professions Code) Code) orthat he is, exempt therefrom and
the basis for the alleged exemption. Any violation of Sed+or 70315 by any
nor applicant fora permit subjects the applicant to a civil penalty of nmare than
five hundred dollars (5500).
F-1NEW
I, as owner of the property, or my employees with wages as their note
compensation, will do the work and the structure Is not intended or offered for
sale (Sec 7044., Buebuss and Professions Code: The Contrmi license taw
does not apply to an owner of property who Wilds or improves therm, and
who does sachw
work himself or through hison employees, provided that such
improvements arc not intended or offered for sale. If, however, the building or
Improvement lssold within one yearofcomptdbn, the ownerWilderevi+l have
t"ed of proving that he did not bund or improve for purpose of sale.).
L as owner of the properly, am exclusively contracting with tlansed
contractors to construct the pmjed (Sec. 70K Business and Professions Code:
The Contractor's Llanse Law does nor apply to an owner of properly who
b IIA or imroves pthereon, and who contracts for such ptojects with a
}}LLt{Tadoi I+ansed pursuant to the Contractors License Law.
LI I am exempt under Sec. B & P C for this reason
APPLIANCES -RESIDENTIAL
PANELS
j08 DESCRB'DON
701-1000 AMPS
OVER ]BOB AMPS
SQ. FT. FLOOR AREA
S/SQ.FE.
SIGNS ELECTRICAL
$PECIALCIRCUIT/MLSC
TFMC METER OR POLE [NST.
POWER DEVICES
SWIMMING POOL ELECTRIC
- VALUATION
/7� -
/ J
OUTLETSSWITCHESFIXfURFS
RFSIDENUAL ELFCTR SQ.PL
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN & VENT WATER (EA)
OCC. GROUT'
UNRS RIS.
FMCYD
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
QUIal E FITS
Owner Date
WORKMAN COMPENSATION DECLARATION
emby affirm that I have a certificate of consent to self -insure, or a
mFtiliutecfWorkeri Compel -VaH Insuranaorarerlifledropythemof(sec.
MOD, Lab C) .C�IO,�D3
Policy # L</
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N
RECEPT #
FIXTURES PER TRAP
SCI )L TAX Y: -W:::—
RECEIPT'#
GAS EA. SYSEEM-I INCA 01
GAS EA. SYSTEM 4(EA)
PARK FEE Y_ N_
RpCEEET#C'ECert_flcd
-OVER
BUILDINGDIVISION FEES
copy is Hereby fumished.
Fzjccrlified copy is filed with the city inspection division.
�0— CERTIDUTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th+ssedimmei not becompleted lithe permit Laforonehundred dollars
($100) Blyth
Isnot emanon the person
Permit is ho the
I shall not employ any person In any manner n az to becorre subject to the
numork so as to become
Workets'Compensation laws of California.ATER
ornia.Date -
Applicant
NOTICETOAPPLICANT:If, aker making chis Certlfkate of Exemption, you
should become subject to the Workcn' Compensation provisions of the Labor
Code, you most forthwith comply with each provinces orthis permit shall be
da"'edmOOked.
CONSTRUCTION LENDING AGENCY
1 hereby a farm that there is a construction lending agency for the perform
ance of the work for which this permitE Issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I ceNfythat I havemadth3sapplicatlonand statethat theabove Information
u correct.1 agree to comply with all erti county ordinances and state laws
relating to building consrmctmin, and hereby authomm representatives c f this
dry to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmi the City of Cupertino
ago labllities,pdgments,00rtsand expect w hmayinanywayaccrue
ag ns old Cil Incense eine gram chis permlt.
q" G
si store of Applicant/ cants or Date !
HAZARDOUS MATERIALS DISCLOSURE
Will the applics"i future building occupant store or handle harardous
mzterialasde0ned by the Cupertino Municipal Code, Chapter 9.12, andthe
1 r-1 Ye9d Sally Cadet fFdloon 75532(a)1
Will theapplicim, (u re building occupant use equipment or devices
which emit harardoma ntamfiemi defined by the Bay Area Air
Quality ManagementD co
o
have read them a oes materials mqulrements under Chapter 6.95 ofER
the California Health & Safety Code, Sections 25505, 75533 and 25534. 1
u nderstacad that if the building does not currently has a tena nh that it is myMECIf
tbllityrondBytheoecvp tof the 1 is which rwst bemetlssuan o(a Ceflea pa // r//' <-4"r
GREASE/INDUSRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei t#
GREASE TRAP
SEWER-SANTTARY-STORM EA. I(i
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Recei t#
SYSTEM/TREATING
NEW'READENTIAL PLMB.SQ,FE.
TOTAL:
BUILDING FEE
0
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIRHANDLING UNrrr ETOI0,WOCFxU
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL:
AIRHANDLINGUNTr(OVER10,000CFM)
FXHAUSTHOOD(W/DUCT)
'
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Reaei t#
000 B'C(p
HEATING UNIT (OVER 100MRESIDENTIAL
3 r
FAN (SINGLE RFSID)
�s�TOTAL:
ISSN ATE
C C p A �as�*
(617 1l V4 i
✓Cu�(
ISSUED BY: P�-
BOILER -COMP DEEP 100,0(10 BTU)
100,000 BTU)
SQ.I7.
lY)TA L:
aulhonred agent Date1
OFFICE COPY