21009 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlfiotlon PERMITNO.
Building Address: 21009
(e N GU u u
n sea asst: p
e) Ue g 914SCIV-S - ?S CITY OF CUPERTINO-BUILDING DIVISION l� �O
Contactors Name: Lic.No: APPLICATION / PERMIT l
BUILDING-ELECTRICAL-PLUMBING-MECELkNICAL CATEGORY CONTROL M
Architect/Engineer, Lie.Nex
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE c cr ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(comment APPLIANCESRFSIDENTIAL ]OB DESCRIPTION
If reel infullforcta deffeon3ofthe Businessand ProfessloneCode,and my
UP TO 2DO ANIPS
license b In full form and effect. PANELS r f I-
LlcenseCla® LIcY
Date Contractor
ARCHITECPS DECLARATION 201-10WA.MPS At
QZ I understand my plans shall be used u public records. OVER1000AMPS SQ.FT.FLOOR AREA 9/SQ.FT.
O
Licensed Professional SIGNS ELFfTRICA
G w - OWNER-BUILDER DECLARATION
I herebydBmtthat lamexempt from the Contractor's License Lawforthe SPECIAL CIlZCUIT/M t
following reason.(Section 7031.5,Business and ProfessionsCode:Any city or TEMP.M R POANST.
_4t'� cmntywhichrequi apermitmmmtmd,alier,impmvgdemolbh,orrepalr
anys[mctvre priorto its Issuance,also requlresthe applicant for uch permit to POWER DEVf
Vfile a signed statement that he Is licensed pursuant to the provisions of the
3 u, Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING WL ELECTV
sion3 ofthe Business and Professions Code).rthat he is exeretherefroma rad VALUATION
Sn S the basis for the alleged exemption. Any violation of Section 7011.5 by any xETS TCI B:S Eq
applicantfora perent suci
bjesthe applicant to a dvll peraity of ect moan than
live ndred dollars(5500). R' AL TR SFT. STORIES TYPE CONSTRUCTION'
I as owner of the property,or my employees with wages as their sole
t�7¢ ca unsation,will dothe work,and the structure Is not Intended or offered for
��0 sale(Sec.7044,Business and Profeaslors Code:The Contractors License Law
OR does not a pply to an owner of property who Wilda or Improves t hereon,and OCC.GROUT' RES.UNITSEE who doessuch work himseUortherugh bis own employees,provided that such
Improvements are not intended oroffered forsale.If,hoveevep the Wilding or TOTAL:
Improvement Issold within one yea rof completion,the owner-builderwill have
t1lt¢urden of proving that he did nes Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mratrun the project(Sec.7044,Business and Professors Cade:
Ile Contactor's License Iaw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffNN
Wilda or Improves thereon,and who contracts for such projects with a
co dor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
1 11 am exempt under Sec. B&P C for this reason BAIX FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner Date - - RECQPT p
N
ORKMACOMPENSATION DECLAR TION FIXTURF$PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate o!consent to self-Insure,
ora RECE PT Y
cedificate.fWorkeri C.mpersallonlrsunnce ora ceril(led copy themo((Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.) RECEBT p
C.I'. Y GAS F.A.SYSTEM-OVER dIRA) BUILDING DIVISION FEES
an
❑pCeyrtlfied copy Is hereby furnished. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
❑CcAifled copy Is filed with the city ImpeaHon drolalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANTIAAY-STORM EA.700FT. Date Rccei t#
(Thlssectlon need not be completed if the perent Is forone hundred dollaro
05100)ml..) WATER HEATER W/VEM/FLLCTR ENERGY FEE Y_ N_
I
cerilftffi071'
orof the wok for whlchthispermRlsiuued.I shallnon an mannereoWATER SYSTEM/TREATINGY PAID
Wrke- fCalifomiaDateO npphamany:, Date Remi t#ZZNOTICE nter makingthIs Ccriiflote o(Excmption,You NEW RESIDENTIAL I'LMB. SQ.FT.
Hshould become aubj¢t to the Workers'Compersation provIsiors of the Labor TOTAL:
� W Cod,you must forthwith comply withsuch provlsimumthh,pemdtshallbe QUI NG '
I C j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ibeerbyaffrm that there is a construction lending agency for the perform- Torpl: ELECTRICFEE t
M Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) PLUMBING PEE
Vlender'.Na
O me
LL I- lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
IcertBy that l have read this application and state that the above information
O W
C. is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to Wilding construction,and hereby authorize representatives ofthIs
I'_ city to enter upon the abovccmention,d property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to cave,Indemnify an d keep harried.the City of Cu Perim. Date Receipt#
V agai HUT, It cost
s,Judgments, s and expenses which may inanywayaccmAI
e R HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
ag is CC y in consequence of the granting of permit. CONSTRUCTION TAX
�j AIR HANDLING UNIT(OVER 10,W0CIM)
Slgnatvrc o(App cant/Contractor a—)� EXHAUST HOOD(W/DUCT)(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hazardous HEATING UNBT(T0100,000 BTU) Date Recei t#
I materials.defined by the Cupertino Municipal Code,Chapter 9.1;and the
health and Safety Code Sect' 32(a)7 HEATING UNIT(OVER 100,000 BTI. TOTAL:
❑ Yes o S1
Will the applicant or lawns building.eevpant use equipment ordevices VENTILATION FAN(SINGLE RESID) - ANCE DATE
which cent hevrdm a air romaenrams as defined by the Bay Arca Air _
alality Management District? BOILER-COMP OHPOR 100,009 BTU) A?
Yes
1�es�
4 vc y
have read the hares smaterials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU)
CaliforniaHealth&Safety CodeSections 25505, 33 and 25534.I Ofunderstand that building does not co4,have at �
b my NEW RESIDENTIAL MECN. SQ.FT 1[
r s ,ibilit Door ify the of the requirements which must be met
PJner Ora an .fa Certificate of Om pa racy.
A Ar 01-17 p .
tWR.cdagent Date TOTAL: ISSUED BY
0FFICE COPY