21940 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'et Identification PERMIT NO.
Building Address: 21940
2000Lt. Nvr+t W1'.Ld Lar YG
TYP—nota arrc//:�� T one: p p
It S/601t- S`('23 CITY OF CUPERTINO-BUILDING DIVISION �/ q /
Ptcpntretorawme: Lie.No: APPLICATION /PERMIT 3-- 6 — C /
Arehltect/Engineer. Lie.No: BUILDING-ELECTRTCALPLUMBINGMECHAMCAL CATEGORY CO OLN
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERhIITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affbm that l am licensed under provisions of Chapter 9(.no APPLIANCESRESIDENEEIAL ]OB DF 141110N
Ingo th Se Uon70M)of Asion3ofthe Businemand PmfcaslonsCode,and my ,
license is in full to.and effect. PANELS
License Clans Lie.#
Date Contractor UP TO 200 AMPS �j�✓ �--tl.
ARCHITECTS DECLARATION 201-IODOAMPS
re
X I understand my plans shall be used a public records. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.IT.
O
Licensed Professional SIGNS ELECTRICAL'
OWNER-BUILDER DECLARATION SPECIAL CIRCIRT/M6C .00
(.., 7 Ihercby a(Orm that!aro exemptfmmthe Contractor's LlcenwUwfmthe
�0 '� following mason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
OLcounty which mquires a permit to construct,alter,Improve,demolish,or repair
FEn
SI anystmctumprlortolta�ance,al requimatheappBraniforsucispermitto POWER DEVICES
c.U lite a signed statement that he is licensed pursuant to the provisiona of the
Contradorb License Law(Cha er9(commencin with Section 7000)of Divi- VAL N
OOj sion3ofthe Business and ProfemlonsCode)orthatt he b exert therefromand SWIMMING POOL ELECTT(IC
e the basis for the alleged exemption. Any violation of Section 70312 by any OUMETI SWIMFEES}IXTURES e o 1`/ V
4b' «
applicant for.permit mbjnts the applicant civil penalty a not morcthan JL/ V
n OO five hundred MoiWNEW RESIDENTIAL ELFLTR W
s($500). SQ.Fr. STO ' TYPECONSTRUCTION
H'yam' ®®I ow f the property,or my employees with wages as their sole
C'�a erJTpensatlon,wBldothe work andthe structure is not intended or offered for ��
O sale(Sec.7066,Businessand Profemlons Code:The Contractor's License law
I $ don not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
EE.• who does such work himself or through his own employees,provided that such �.
improvements are not Intended proffered for sale.IL however thebuilding or TOTAL:
Improvement bsoldwithln one)earofcompletion,theowner-builderwlll have
t"rdenofPmvingthathedid nabuddorlmproveforpurpoacofsale.). QTY. PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to construct the project(Sec.7064,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such Exojecn with a ALTER.DFUN&VENT-WATER(EA)
,SEgt ator(e1 Rmosed pursuant to the Contra cto s License Law. FEE SUMMARY
LI 1 am empt u r Sec. B A P C for this reason BACK FLOW PROTECT.DEVICE
-1 ITSI DE FEES
ens n DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
Owner - Date RW- 1111T'N
Wcflt A COMPENSATIO. DECLARATION
❑I hereby affirm that I have a certlRat of consent to self-Insure,ora FI%TURESPFR TRAIT SCITOOL TAX Y N
RECEIPTNN
certificate of Workere'Comperoatim Insurance ora cetUfled copy thereof(Sec. GAS FA.SYSTEM.1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT p
Polley Y GAS EA.SYSTEM.OVER 6(EA)
Cpm any BUILDINGDIVISIONFEES
�
Cedified copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SElVFR- STORM-STORM EA 200FT Date Rccci I#
(Thlssectlon need not mi
be completed If the permit is for one hundred dollars
(5100).rhux.) WATER I-[eA'I'[R w/VENT/ELECTR ENERGY FEE Y N
I mrtRythat In the performance of thework forwhich this permit is issued,
1 shall not employ any person in any manner so as to become subject to the WATER SYSI.FM/TREATING
Workers'Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFI. Date RCCCI L#
Z O NOTICE TO MPLICANT:R,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compewt tors provisions of the Labor TOTAL:
N Code,you swat forthwith comply with such provisions or this pennit shall be UI NG
W deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
ll Ihembyafnrmthxtthemisa construction lending agency for the perfortry TOTAL: ELECTRIC FEE as V
Z once of the work for whichthb=t b issued(Sec.3041,Civ.C.)
02 Lenders Name PLUMBING FEE
U. L— Lender.Address QTY. MECHANICAL PERMIT FEE
O w ImNfythatl havereadthisappliatbnand statethatthcabovelnformat(on MECHANICAL FEE
d is l dgme to comply with all city and county ordinances and state laws PFRMTTLSSUANCE FEES PAID:
>. relating to building construction,and hereby authoriu representatives of this
I IA city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
Vliabilities,' d ts,costs and ex which may clue AIR1 NDLING(IMT(TO 10,"CFM)
againstAgmen expenses yinanywrya SUBTOTAL:
against CI �(, sequenc the granting this permit.
�_ ��/ �q� NR HANDLING UNIT(OVER IO,000CEI) CONSTRUCTION TAX
s�gna( Apply/am2ootraemr Date f EXIIAUSTHOOD(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) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ,and the
Ile❑althand Safety Codlee Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:en . S3e�
No
Willtbeapplia not or2wt lulldiR,p pantuseequlpr ntordevices VFMILATION EAN(SINGLE RESIDE IS {sI ATE
which emithagementsair contaminants as defined by the Bay Arca Nr SOW
Quality Management Diir 'at BOILER-COMP OFm OR 100,fXq BTU)
Yea No
lhav ..dthehaza ousmaterialsrequirementaunderChapler6.95o( BOILER-COMP(OVE2100,000 BTU) MAR 1991
the California Health k Safety Code,Sections 75505,75533 and 75534. I
understand that lithe building does not curmntly have.tenant,thatlt is my NEW RESIDENTIAL MECH.—SQ—FT. p
responsibility to notify the occupant of the requirements which must be met pp��Ys�{!CII -a.-1
prior to issuance of a Certificate of Occupancy. 4,N)
Owner or aulhorimd agent Date TOTAL: ISSUEDBY
OFFICE COPY