21891 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
building Project Identlfintion 7 PERMBTNO.
Building Address: �-^ �•^� 218
18 9 1
TY7ner79.W: one, AL DA
}� � •Z`j•�-9c CITY OF CUPERTINO-BUILDING DIVISION
Cost ctor'aName: \ � II No: APPLICATION / PERMITFCC
V vJ —1 BUILDING-MFC'IRICA4MTJMBINGMECHANICAL CATEGORY coil LD by
Arch ed/Engineer, LIB No: `�C�-R�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: , e1 _:l . rt-yi
I'ERMRTISSUANC'E 4CY/
LICENSED CONTRACTOR'S DECLARATION
lhereby
ectionr70 that)amlkmsofthe Bu prossand eo(Chapler9(commmc APIsLIANCESRESIDENf1AL '. JOB DESCRIPTION
Ing with 1.NU
force of and affeon3o(the Bu/w�ne�sayan�d�l'r�ofn(slo�nsCode,and my
License Class B force and de N ��'L"Y K//•f PANELS Po^IJIJ
..
Date Contactor
ARCHITECT'S DECLARATION 201-1000 AMPS -
M7 I understand my pore ahaR W used u public recordw OVER 10DO AMPS SQ.FT.FLOOR AREA •$/SQ.FT.
� O
d�j Licensed Prdmbnal SIGNSELECTRICAL
<Q OWNER-BUILDER DECLARATION,
t; SPECIALCIRCUIT/MISC
1p..• 7 owinbyasormlhatlam31.5,Bexempt lromlhed Professions Code:
law tort he
Ogt.� following Mason. 7RI1.5,Business Pmfmlom Code:Mydty or TEMP METER OR POLE INST.
countywhichrequresaper tWwnstmd,Oteglmpmve,dem llf h,orrepair
F .'a-: anystrudun priortolts issuance,alsorequirolheapplicant for such permit to POWER DEVICES 2 tCl2
6 file a signed statement that he is licensed pursuant to the prov sks.of the
Ow Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
30e' ebn3ofthe Buslnmand Pro(mioreCod<)orthg lasts exem them(romand VALUATION
�"S the bash far the alleged exemption. Any violation of Section 7031,5 by any. OUTLETS—SWITCHESSFIXTURES ^]._2 QC)d. CA9
appBantforapermitsubjedstheapplfcantioadvilpewltyofndnnrethan
five hundred dollars($500), NEW RESIDENTIAL ELECTR SQ.FT. STORIES'. TYPE CONSTRUCTION
co
(; G F-11,as owner of the property,or my employees with wages as their sole
compensation will clothe work u
and thesucture V rot intended or offered for
5 ❑ sale&c.7(Ry Buslnm and Professions Cade:The Contractors Licenselaw
don not apply to so owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
0.0. whodocessuch work himxlforthrough hbownempi yees,providecithatsuch
improvemenlsare not intended oroffered forsalc.If,however,the building or TOTAL:
Improvement issold withinoneyearofcompldbn,theuwner-bullderwlll have
thekurden of proving that he did notbuild or improve for puryme ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE, APN,
LJ[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mvtruct the pmjM(Sec 70K Business and Profminre Code:
The Contractor's License Law does not apply to an owner a property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon,and who contracts far such plojects with a
,,IlIlSTmkor(s)licensed punuaat to the Contractors License Law. FEE SUMMARY
c BACK FLOW PROTECTDEVICE
LJ I am exempt under Sec: B &P C for this rcasoe .
OUTSIDE FLES
DRAINS-FLOOR ROOF,ARECOND. SANITARY Y_ N_
Owner Date A, RECEIPT If
�s WORKMAN COMPENSATION DECLARATION FO(II)RES I'EI2772,1P SCI TAX Y_ N_
❑1 hereby affirm that 1 have a cadifle is of consent to self-Insure,or a RECEQ /
certifiate ofWorken' persatlonlvurance oracertifled copy tFereo((Sec. \ GAS EA.SYSTEM-11NCA OUILLTS 2s CW PARKITT Y_ N_
3800,1ab C.) 1
Poli#p RECEIPT DI a
� arse GASEA 4 7 BUILDING DIVISION FEES
ce copybhercby(umished. - GREASE/ Du PLANCI-IECKFEE
❑ rtified copy is filed with the city inspection division. ,.
CERTIF'ICAIEOFEXEMPTION FROM WORKERS' GREASE JVJPAID h
COMPENSATION INSURANCE SEWER-SAMT Y-STORM EA.200FL Date Recti t# dj aZ-�
sena
,:(This ction need e be complded lithe permit la foram hundred dollars
($100)or less.) - WATER HEATER WIVE" EN RGY FEE Y_ N_
Icertify that In the performance of the work for which this penult is issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worker%Compensation Laws of California.Date PAID '
0 Z AppliczmNEW RESIDENTIAL PLMB. SQFT. .Dale Remi t#
Z O NOTICETO APPLICANT:If,after making this Cediicateof Exemption,you
Fshould become subject to the Worluam Compensation provlslons ofthe Labor TOTAL:
W Code,you most forthwith comply with such provisions or this permit shall be
5 deemedrevaked. BUILDING E07
W — CONSTRUCTION LENDING AGENCY - SEISMIC FEE
n C Ihenbya(imthat there is a mmtrudion leadingagenryTOTAL, ELECTRIC FEE
(a,the PsHerrm 3
Z arm.fthrworkf.rwhEchtMs permit bissuM(Scc.3097,CIv.C.) - - �� PLUMBING FEE x
(� O Lander'.Name
Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertifythatl haveread this application and statethatthe above Information
0 W
V correct.I agree to comply with aft city and county ordinances and gate laws PERMIT ISSUANCE -2-&/ FEES PAID:
} U) relating to building cons"etion,and hereby authodae representatives of this
U) ray to enter upon the above-mentioned property fm Inspection purposes. ALTER OR ADDTO MECH.
_ Z
(We)agree to save Indemnify an d keep harmless the city o(CupertNo Date Receipt#
jed
O against liabilities, coatsande ass
may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agamstsaid Ci - nceof granlln ofth It. 1 ,
AIR HANDLING UNIT(OVER IQWO CFM) CONSTRUCTION TAX
s' a o
Data HVA3IKT) CONSTRUCTION TAX PAID:
HA2AMATERIALS DISCLOSURE
Will theapplicantofuture buddingodupant storeor handle haeardoets - HEATING UNIT(TO 100,ODO BTU) Date Reccei t#
material as dented by the Cupertino Municipal Code,Chapter 9.1;and the -
HmlthandSafetyCodcr�Scctbn25532(a)? HEATING UMT(OVER 100,0110 BTU) L�' TOTAL:
Fly. , u No + -
Willtheappllcantorforam Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit W vrdum air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OTR'OR IOQ000 BTU) p
4Yes ❑❑No PAID
havereadehchvrclousmateriasrequlrercnisunderCWper6.95of OLER-COMP(OVR100,000B7U)
the California Heahh&Safety Code,Sections 75505,25513 and 25534. I MAR
understand that lithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.1'T nn q
responsibility to notify the occupant of the requircomets which must be met 8 �tlJ
prior to issuance of a Certificate of Occupancy.
'Owner or authorimd agent Data TK TAh: (� ISSUED BY
OFFICE COPY