21542 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY .
Building Project ldentlfkatlon PERMIT NO.
BuOding Address: r _ 1 •,
21542
Ph
H a. CITY OF CUPERTIN6BUILDING DIVISION
APPLICATION / PERMIT a
BUILDING-ELECTRICAI.PLUMBINGMECHAMCAL CATEGORY CONTROL p
Architect/Engineer; -
u0 i
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO '
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION 0 D
I hereby affirm that am licensed under provisions of Chapter9(commenc. APPLIANCES-RESDEN71AL J08 DESCRE'[i�1V
2wlth Secti.n )a(Dlvlslon3o ellusJLs...d ProfesMonsCods ruieny /
.seta In(u f effect. PANELSLicense,C Lie.N
_
Date Contrai[or UPTO2D0AMPq (�-
21-I"AMSTECSARCHI
4-
0 0Ocor
I understand my plans shall be used as public reds OVER 1000 AMPS SQ.E7.FLOOR AREA $/SQ.Fr.
car U5 Licensed Professional - SIGNSELECTRICAL ^
Zt 6 f y OWNER-BUILDER DECLARATION SPECLILCE2CUIT/MLSC
aThr' Ihereb a(flrmtlutlam exempt Contractor a Llrenx Lawforthe
O2F following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP. CREOLE ST.
P� county which requires a permit to construct,alter,improve,demolish,or repair
qq any structure prior to its lasuance,also requires the applicant for such permit to pOWpR DEVICES
19 file a signed statement that he is licensed pursuant to the provisions of the -
3 w�, Contractor's License Law(Chapter 9 from ounclng with Section 7000)of Divi- SWIMMING Poo EGTRIG
COs
Won 3of the Business and Professow Code)orthat he is exempt therefromand VALUAT ON .
0Q the basis for the alleged exemption. Any Wolatlon of Section 7031.5 by any 'OUTLETSSWI HESFIXTTI2E5
n tv`
applicant fora permit subjMatheapphcanttoacivil penalty ofnet morethan
^� five hundred dollars($500). NEW RESID AL ELECTR.
p••�n ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,willdothe work andthestructure boot intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractors Llcerue Law
$ does not apply to an owner of preperty who builds or improves thereon,and
who does suchwurk himself or through his awn employees,provided that such OCC.GROUIs RFS.UNITS
improvements are not Intended mattered for sale.ILhowevegthebuildingor T -
improvement lased wllhm one yearofcomplM(oM the owner-bullderwlll have
the burden of proving that he did not build crlmpressforpurposeofsalnJ. QTY, PLUMBING PERMITFLOODZONE APN
u L as..or of the property,am exclusively......-Ming with licensed PERMIT ISSUANCE "
contractors to construct the protect(Sce.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(E,U
Wilds or improve thereon,and who contract,for such plojects with a
cgR((actw(s)licensed punuant to the Contmetee Llreme Law. FEE SUMMARY
BACK p[qW PROTECT.DEVICE•
LII am exempt under Sec. B&P C for this reason1Z Ql1TqinF.FEES
Owner Dare DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y - N_
RFCSFT#
WORKMAN COMPENSATION DECLARATION FIX TURES PER TRAP - SCHOOLTAX Y N
hereby affirm that 1 have a certificate of consort to coif-in,urc,or r RECEIPT Y a -
�. fimtteeofWorkem'Compematlonlmuranre ice edcopythereof(Sec.4WATMMER
F.A. STEM-I INC.40 S PARK FEE Y N
U. j1/�
Polity p L,i(" `' - REICEB'I p
' Com any F.A. SI'FM-OVERd ) BUILDING DIVISION FEES
Cert coy reby a DUSTAL W
SHE INTERCErroR PLANCHECK FEE
�{lrerlifled copy Is(lied with the city W pact Ivislon. ,
O� CERTIETCATEOFEXEMPTION FROM WORKERS' AP PAID
COMPENSATION INSURANCE K STORM EA 200FT Date Recei t#
IThiseecbon need not bec.mplMed lithe permit b(or one hundred dollars
($100)-r less') WATER W/VENT/ELECTR ENERGY FEE Y N
I certify that in the performance of the work forwhlch this permit is issued, -
I shall not employ any person In any manner so as to become subject to the /.TREATING
Workers'Compensation Laws of Glifomia.Date PAID
0 Z Applicant
Z Q NOTICE come wbIC t to the orkerak omper �alfationk rovism.f Exemption,you
NEW DENTIALPLMB. SQ,Fr. Date Recei t#
Code,shoulyou
at drthwit the plyyere'Compematllnacvthis permit a Lab be ' TOTAL:
L
Cagyou muet(orthwilh comply with such provisions..thio permit shall be BUILDING •E
� j deemed revoked. � -
d5 � CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z a I hereby affirm that there is a constitution lendingagenry,for the perform- - 0TELECTRIC FEE
nce "
7 of the work forwhich this permit is issued(See.3097,Civ.C.) 7AL:
V O [enders Name - - PLUMBING FEE
LLF Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W_ Icekifythat l have read this apphatlon and shorthat the above Informstion - r� V
iscomet.Iagmeto comply with all city and county or and Mate laws PERMIT ISSUANCE rT• FEE$PAID:
} a relating to building construction,and hereby authorize representatives of this '
Z WX4.enteruponthe above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.� y
Fj — e)agree to save,indemnify an d keep harmie he ly of Cupertino Date Receipt#
gal st bit
ties,Pdgmenh,costsand expense c - y anyway accrue / AIR HANDLING UMTIT010,000 CFM) ,j - SUBTOTAL;
agai a Id Ityl m en (the granting oft t
��' QI AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
-Signature of Applicant/Contractor ((//Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous ' HEATING UNIT(TO 100,000 BTU) t - Date "ReCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
Will the applicant cefuture building mcupant use equipment s devices VENTILATIONFAN(SINGLE RE RD) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air -
L Quality Management District? MOILER-CAMP OFT OR 100,000 BTUs Q'
4Yea I�I No
ha ¢read the hav ousmateriab requirements under Chapter 6.95 of BOILER-COMP(OVER10,000 BTU) ep ����
the Celilornia Health&Safety Code,Sections 75505,25533 and 25534.I ! `V s7 ,
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL Flf SQ.FI.
'ompOradolity to notify the occupant of the requlrerrents which most be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data
TOTAL: a ISS
ME u- �
OFFICE COPY