21477 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bulldug Address:
21477Je7ro41y aGjL' e " rne.
A
a JOY\
CITY OF CUPERTINO-BUILDING DIVISION
c traer°ra"a11nte: ILic.No: APPLICATION / PERMIT
Y o lAikWtO� O BUILDING-ELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROLX
Ambit /Engineer.• Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERhUTISSUANCE
LICENSED CONTRACTOR'S DECLARATION �. ®
IMmbyafftr thatlam Bcmaedunderpro Wonnof Chapter9(mmmmc APPLIANCESRESIDENTIAL . JOB DESCRUTION
IngwlthSacion7000)of Dtvbion3ofthe Businessand ProfessonsCode,and my -
license Is In foil fora and affect. PANELS
LicenseClass Lk.N
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
µO
re0� I understand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA s/SQ.FE! qOqSIGNS ELECTRICAL
E�U Licensed professional �
4fn< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC sL n
f, ; Ihercby af0rtn that l am exempt from the Contractors License Law forthe LED �`Vy
OO F^ following reason.(Section 70315,Business and Professions Code:My city or 'TEMP.METER OR POLE INST. T .I 3 G
Z µ37 countywMch req to itsperMtro coorequ,eath lmpmvent for
slyer repair n
anyawctureprirn tolblasuance,aborcqulmtheappBant for such permit to POWER DEVICES i. p 'YL.YI'
1 V file a signed statement that he is licensed pursuant to the provislors of the -
qq Contractor's License Law(Chapter9 commends with Section 7000 ofDivl-
W I"Fn i ( Bw f SWIMMING POOL ELECTRIC
O the basis fo thealle edexemption. Any
rihat lation (Seem therefrom and LUATION
y.'S the beans for the alleged exemption. Any violation of na It Section 70315 by any OUTLETSSWITCHESFIJRURES
0� appBanr(ora permit s°bjectsthe applicant toe civil penalty of not more than
fivePasodemodollarthe OO. SQ. .STORIES TYPE CONSTRUCTION
hundred as owner°f the m NEW RESIDENTIAL ELECTR FI.
1.Z 6compensation
p perry,or he employees with wages their sole
compema0on,Business
work and ions Code: Isnot Intended or ioffend for
��D
sale lSec.7064,Business and professions Code:The Contractors License law
does not apply to an owner of property who Wilds or Improves t hereon,and OCCGROUP RFS.UNITS r
iL whodasssuchwork hlmselforthrwgh hlsownemployees,provided that such
improvements am not Intended oroffered for sale,l(howevegthebulldingor - TOTAL:
improvement issold wlthlnoneyearofcompletion,theowner-bullderwill have
th,9l[I,rden of proving that he dm not Wild or Improve for purpose of Bale.). QTY, PLUMBING PERMIT FEE
Las owner of the prop ,am exclusively contracting with licensed FI-OOD,IDNE APN
J L erty
PFRhfIT ISSUANCE
contrectors to construct the project(See 7044,Business and Professlom Code:
The Cmdeartm'e License Law does not apply to an owner of Property who ALTER-DRAIN&VENT-WATER(EA)
Wlids or Improves-thereon, and who contracts for such projects with a r
,�NU(Tactor(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY
c u l am exempt under Sec B Ar P C for this reason BACK FLOW PROTECT.DEVICE OUTSI DE FEES
Owner Date - DRAINS FLOOR ROOF,AREA,GOND. SANITARY - Y N__ RECEI'f N
M
WORKAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCIi00L TA% Y_ N_
01 hereby affirm that I have a certificate of consent to self-Insure,ora REC=N
cenifiateufWmIcam''Compensation Insurance ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.). RECEIPT M
Policy X GAS EA.SYSTEM-OVER 4(FA)
CDCBUILDING DIVISION FEES
�
certmed copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
.War ified copy is filed with the city Inspection division.
J4,, CERTIFICATE OF EX EM PTION FROM WORK ERS' GRF-ASETRAP PAID
COMPENSATION INSURANCE - SEWER-SANITARY-STORM EA.200FT. -Date RCmI t#
UMs section need na be completed Bthe perndt la for one hundred dollars
(S100)orleo.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y, N—
I unify that In the performance of lhework forwhlch this permit is Issued, .
I shall not employ any person in any manner se as to become subject to the WATER SYSTEM/TREATING
Workers'Compemation laws of Callfomia.Date PAID
O- Applicant Date RCmi t# '
Z NEW RE57DENDAL PLMB. SQ.FT.
Z O NOTICE TOAPPLICt APPLICANT: o,karsk o this Compensation
Exemption,you
should Wrome subject to the Workers'Compensation prdvisl°ro of the Labor TOTAL:
w Code,you must forthwith comply with such provisions or this permit shall be BUILDING CC darned revoked.
W aCONSTRUCTION LENDING AGENCY SEISMIC FEE
a 1 hereby affirmthatthem 6 a construction lending agency for the perform, O ELBCTRIC FEE
M Z ance of the work for which this permit la Issued(Sec.3097,Civ.C.)
V O 'Tenders Name• PLUMBING FEE
LL F Lend ere Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icart lfy that l have read this application and state that the above information
1 bcorrm.iagra to<omply with all city and county ordinanmand state laws PERMUISSUANCE FEES PAID:
r relating to building corstructlon,and Mrcby authorize representatives ofthis
N it to entero on the above-mentioned roe for inspection purposes. ALTER OR ADD TO MECH.
I— Z o Y P property harmless
P Pum Date Remi t#
(We)agree to ave,Indemnify a keep harmless the City.(Cupartir.acerae P
V agalmtllabllities,' dgments, ex rases which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aI Ci n atM ting of this permit.
9 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
5 wture of Apph. Nmct°r I Data EXHAUSTHOOD(W/DUCT?. CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI 1#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
licalth end Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yell MN. "
Wllltheapplicant or future building occupant use equipment orcievias VENTILATION FAN 6INGLE RESID) I$'9UANCfPATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP C3HP OR IW,"BTU)
❑ Yes NO 1.71994 e
�• Ifferead Health
Safety
mode, ectiommmcnbunder Chapter 6.95 of HOMER-COMP(OVER 100,000 BTU) FEB
the understand
If the
building Safety does,Sectiore currently
have a tenant,and t,xhat It
usporointlyto ntifytheoccupant of to requirhents whthat b meta my NEW RESIDENTIAL MECIi. '�.FT.
poor tomWtyto of a theoccupantof ofpare<prlmmentuwnirn most Wmer CIlJt I,UYtHllltl(J
prior to Issuance ole Certificate ofOccupancy.
Owner or authI n,ed agent - t , Data r - ISSUED BY:
TOTAL: '
OFFICE COPY