21090 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Ptojed IdentificationP' MITNO.
Building Address: a e( 21090
l� /a
sonars acre: one;
CITY OF CUPERTINO,BUILDING DIVISION I O
tea o'eName: APPLICATION / PERMIT
BUILDING-ELECTRICAL PLUMBING-MMIUNICAL CATEGORY CONTROL Is
Arehitect/Eagineen. Lle.Na:
QTY ELECTRICPERMCr PEE BUILDING PERMIT INFO
Addmae: - PERMIITISSUANCE 71 ❑ ❑
•LICENSED CONTRACTOR'S DECLARATION "
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPLIANCES REBIDENTfAL JOB DESCRIPTION
IngwlthSection7000)01 DlWsion3ofthellusinessand ProfeaslonaCode,and my
Iicensa is in full once and
Llcenaa PANELS
lam Lie.0
Dat ContraRor_ /V•-••e-�
ARCHITECT'S DECLARATION 20)-1000 I5
MZZ I understand my plans shall be used as public records. OVER 1000 AMPS. SQ.FT.FLOOR AREA S/SQ.F(.
dLicensed Professional SIGNSELECTRICAL
«< OWNER-BUILDER DECLARATION
In 6 6PECLILCIRCUIT/M
zL, )herebya(0r (Sadtla 7exempt fromes sad Preltlsho..Cde:Any fart he
following reason.(Section 70)15,Business and Pro(essiom Code:Any city or
Fg TEMP.METPR OR LE)NST.
� anystm�ntyhkhr ortoit imattemorLqut l Cheap li entf much, er ttr
anya signed statements that
he e,also sed Pursuant to the provisions
of t e POWER DEVI
IWbS�0.S file a signed statement that he Is licensed pursuant to the pmWlom of the
3�G Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING LELECTRIC
no
sion3ofthe Businessaad Profession Code)rrthat he Is exempt thercfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7071.5 by say OUTLE TCFIFSWXTUR
applicant fora permit subjects the applicant to a civil pass try of not marc than
49
Rve hundred dollars(1500).
�n ❑1,as owner of the property, NEW ESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
p party,or my employees In with wages r thele sola
c 1.(Se.70K Business
the work and the structure The
not Intended or...L far
O dale(Sec.apply
to alnowendf pressloss Code:The Contractors Llcesse Law
$$ doesnotapplytoanowncro(pmpgh hi.o nemoyees,povidedr improwes that
OCC.GROUP RES.UNITS
whodansuchwarkhlmseBorthrough hleownemployees,provkledthat such
Improvements are not Intended oroffemd forsale.IL howeveq thebuilding m TOTAL:
improvement lawld within omrarofcompletioN the owner-builderwlll have
tlj, urden of pmving that he did not build or impmve for purpose oleate.). QTy, PERMIT FEE }7-pOD ZONE APN
�j I,as owner of the property,am exclusively contracting with Ilcen
contractors m construct the project(Sec.7064,Business and Protections Cad P U
The Contnciar'a License Law don not apply 10 w owner a4 property soh A I -WA
builds or Improves thceoM and who contracts,for such projects with
TTcq�((actce(s)ficensed pursuant to the Contractors License Law. BACK PRO T. FEE SUMMARY
I am exempt under Sec. B k P C for this re nOUTSI
DRAINS FLOORR A CND. SAMTARY Y N-
FEES
Owner Date RECEIVE N
•• WORKMAN COMPENSATION DECLARATIONPC•I SCITOOL TAX N_
Y_
Ig1 hereby affirm that I have s mrtlRote of consent to self-Insure,or.a, FBXTVRFS y—RECEIPT p
<rt flatemfWorkem'Compewtionimuranmoramnifiedmpyihemof(Sec. CAS EA. -I C60 ETS PARK FPE Y N
3BOo,Iabca OYw��- 2(fr39-G RECEIPT«
Coc p
Cc G.SY 4(PA)
U L BUILDING DIVISION FEES
(�CertlOed copy Is hereby tthcity
e city inspection division.e
enNed copy b filed with thCREASE/INDUSTRL WASTE i EPTOR PLANCHECKFEE
CERTIFICATE..OF UEM PI TON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlssedtooneed not becompleted if thepermlt leforonehundreddollars SEWER-SANITARy-STO EA.20067. Date Reoei til.
(1100)orl..) WATER IiFJ.TFR W/ /111113)mENERGY FEE Y N
I remlythat in the performance of Cha work for which this permit is lamed, —
I shall not employ any person in any manner w n to become subject to the WATER SYSTLM/ EATING
Worker'Compensation Laws of California.Data PAID
icant
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you NEW RESID AL PLMB. SQ.Ff. Date Recei til
Hshould become subjectto the Workers'Compewtion provisions of the Labor TOTAL:
N Code,you at forthwith comply with such provIsloss arthIs permit ahallbe BUILDINGE
W j deemed revoked.
tl O CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyaBirmthattherclsaconstmRlon lending agency for the perform- TOTAL: ELECTRIC FEE
M Z ance of the work for which this permit Is Issued fSec.3097,CiV.G.)
V O Lenders Name PLUMBING FEE
LL f Lendee.Address QTY. • MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certllythatl have read thisappliestlonand statethattheabove Information
IL Is correct.l dgree to comply with all city and county orduseresand state laws �. PERMITISSUANCE OC� FEES PAID:
>. W relating tobullding comtmctlon,and herebysuthorize representatives of this -
Z city toenterupon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Me)agtte to save,Indemnify an d keep harmless the City of Cupertino Date ReCeiptM
V against llabllitln,pdgments,cone.ed expenaeswMch mayln anyw.ysc.a AIRILANDLING UNIT(TO ID 00CFM) SUBTOTAL:
against spp��aa C�ity,ry� e..quencaofthegrantingofthia permit '
l� I(7T( ��i di;6 AIR HANDLING UNIT(OVERIO,000CFM) CONSTRUCTION TAX
Slgsstem of Applicant/Contractor //�, Data IXHAUST I IOOD M/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheappIlant orfulurebuilding occupant store or handle hazardous / HEATINGUMT(TOI00,000BTU) � Date RCcei t#
material as defined by the Cupertino Municipal Code,Chapter 932,and the _q, - atp�
Ilsslthand Safety Code
de Sedion2S532(a)7 I[EATING UNIT(OVER 100,000 BTU) T sW
Yes No
Will the applicant car turc building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUqANCE DA RE--
which et hazardous air contaminants as defined by the Bay Area Air
Quality Massm
geDistrict? V�7t District? BOILERCOMPQIIPOR 100,IX0 BTU) G I199
Ya ❑No 1I JJ JJ
Ihaveread the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ptpss
,r n.
the Californiala Health k Safety Code,Sections 25505,25533 and 25534.1 f '
understand that if the building does not currently haveatenant,that it Is my NEW RESIDENTIAL MECIi. SQ.FT. , �11110p�/pA
nspomlbllity/o naity the occupant of the rcquiremena which must be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data ISSUED BY:
TOTAL /.
OFFICE COPY