21981 (2) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - - • PERMIT NO.
Building
.Address:
wner21981
19na
araAAlh
�Y
�Z IL.ae CITY OF CUPERTINO-BUILDING DIVISION - C�
co araName: Lie.No: APPLICATION /PERMIT
rchitect/liest Lic.No,
BUILDING-¢ECTRICAI.PLUMBING MECHAMCAL - CATEGORY CONTROL
t r` t, ,'BUIL.. . G E 1. INFO,,.;'1 t'._
sQ'tf:' .EGECTRICtPERMIT IF `FEE
Address: , 51. .I PERMIT ISSUANCE 1�
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l am licensed under provisions of Chapmr9(commenc. APPLIANCES-RESIDENTIAL JOB DE3CRE'TION
ingwRh SCtior70EY)of DivbIod3 ofthe Buslnessand PrefessionsCode,and my -
licenseislnful rep and effect. PANES
PtfssI LION' ti'Jt'11�
e Contractor lm rvLii2 s^A—�jjlJa{-J r!1 l- VCU. vt/
ARCH .CIPS DECLARATION 211-1000 AMPS
q9GZ Ise 1 s Ilbeusedupubhe records OVER1000AMPS . .FP.FLOG FA $/SQ.FT.
q��++ COC 1N Sp��a] ��.aµaaapR
Fi�() L�iisel Professlotul SIGNS ELECTRICAL 1 Vep/-/�\ L {� D
<<� l N OWNER-BNLDER DECLARATION SPECIALCIRCUIT/MISC I V
E. I hereby affirm that I am exempt from the Contractor's License Law for the �Y
Zp '� following mason.(Sectfon 7031.5,Business and Professions Code:My city or
O Z rr TQ.MP.METER OR POLE INST.
countywhkh rcqulre.a permit toConstroct,alter,Improve,dennlbh,orrepair 0
am anystmclum prior to its Issuance,also requlresthe applicant for such permit to POWER DEVICES DA TE
file a sload statement that he Is licensed pursuant to the provisions of the i'
�g(Om Contractor'sLicense Law(Chapter 9(Commencing with Section 7000)of Divi-G� VALUATION sion3 of Business and Professlose Code)orthat he exempt therefmmand SWIMMING POOL ELECTRIC D U the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESFU(TURFS S1IV
d a o
appBcant for a permit subjects the appltcanl to a civil penalty df notmore than
Ave hundred dollars($500). NEW RESIDENTIAL ELECTR SQ}T
�n ❑I,as owner of the property,or my employees with wages as theft sole . STORIESTYPE CONSTRUCTION
compensation,will do the work and the structure is not intended or offered for
a sale(Sec.7064,Business and Pmfasslmu Code:The Contractors License Law ----- -
p^�$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITSc0.. whodoessuchworkhimselforthrough hisownemployeas,provided that such
dmprovements are not Intended oroffered forsale.If,however,thebuilding or - ..TOTAL: a
Improvement is sold within oneyearof completion,the owner-bullderwlll have
I� te"rden of proving that he did not build or improve for purpose ofule.). QPY. t•�t'I":'•,PLUMBINdkRMIT) '.FEEli- FTnOD7ONE APN
U I,as owner of the property,am exclusively Contracting with licensed PERMIT ISSUANCE
cuntra tots to Construct the pmjeet(Sec.7044,Business and Professions Code:
I he Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Improves thereon, and who Contracts for such pmjeets with a j
tt[=etor(a)hrensed pursuant to the Contractor's License Law. sd� FEEiSUMMARY, M. \,pi
, Om, exempt under Sec. B k P C for this rcuon BACK FLOW PROTECT.DEVICE -' --
DRAINS.FLOOR,ROOF,AREA,COND.' SANITARY Y N�
Owner Date RECEIPT At
Fr'l1 m WORKMAN COMPENSATION DECLARATION FIXTURES—PEit TRAP SCHOOL,TAX Y_ N
.ul hereby affirchat I haveCertificatee aCertsell-insure,cate of consent to sal(-In ,or a RECEIPT N
urifictim of Workers'Comperesation Insurance ora cerdfled Copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS. PARK ITE '.'Y N
3800,Lab C.) REx N
Po11ryM CAS EA.SYSTEM.OVFR 4(EA)
���Co���pp��55q y BUILDING D IVIS I ON FE ES
ENrtified copy Is hereby furnished.. , CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ^ pp
0 Certl(led copy 6 filed with the city Inspection division. /3•/
-
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM PAID— _/-
1I ,)urs t
COMPENSATION INSURANCE „ SEWER-SANITARY-STORM EA.200FT. Dale Recei t#
(This section need nor he completed if the permit nice ane hundred dollars P (�-ut
($lm>orles.) WATER HEATER W/VENT/¢EGTA ENERGYFEE Y_. N_ !7-UQ
I certify that In the performance of the work forwhich this permit Is funded,
I shall not employ any person In any manner so As to become subject to the WATER SYSTEM/TREATING IJ.6 I l�
Workers'Compensatlon Laws of California.Date PAID
licant
Z•Z NOTICE TO APPLICANT.If,after making this Certillcate of Ezcmption,you NEW RESIDENTIAL PLMB. SQ.FT. Dale Remi I#
F0 sh.ldbecome.ubjecttothe W.rk .'C.mFe..tion pro tC o(the Labor TOTAL: IV-
CC Code,you mu at forthwith Comply with such provisions Mthis pamdt.hall be
W-> deemed revoked. I BVI ING E a
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyafbre thattherelsa Constroctlon lendingagency for the perform TOTAL: ELECTRIC FEE
M Z ance of the work for which thispernJt is lsaued(Sec.3097,Civ.C.)
(J lander'.N.Cre PLUMBING FEE
r Lender.Address Qn. ', MECHANICAL 1IRMIT
•O W I Certify that l have read this application a nd state that the above Information FEE'' MECHANICAL FEE
C I.correct.I agree to comply with all City a nd County ordinances and Mate laws PERMIT ISSUANCE. FEES PAID:
relating to building construction,and hereby authorise representatives of thts
F N citytoenteruponthe above nif red pnrperty for impeelon purposes. ALTER OR ADD TO MECH.
Z -.Date- - Receipt#
_ (We)agree to ave, Ify and keep harmless the City of Cupertino -
againetl0bllltles,' me ,Conte andexpenseswhichmaylnanywayaccrae AIR HANDLING UMT.(I'010,000 CITE) SUBTOTAL:
against uld i neon encs d!the granting of this perm)
• AIA HANDLING IR.TP(OVER 10,000 CFM) CONSTRUCTION TAX
'Ignat eof Applicant/Contractor Data .. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HFIUNGUNIT(TO100,000BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the '
IMealth and Safety Code Section 25532(a)?' HEATING UNIT(OVER 100,000 BTU) TOTAL: L`78
❑ Yen Mid. .
Will the applicant orfulurs building occupant use equipment ordevicee VENTILATION FAN(SINGLE RESID) ISSUANCE DA'L'E
Mich emit haurdous air Contaminant ea.defined by the Bay Area Air
(�ty Management District? BOILFR-COMPOIR'OR100,0001HU)
I� Yea ` No
'' Inave read the ha dn
ousuterials requirementsunderChapter6.95 of BOILER-COMP(OVIR 100,000 BTU)
the California Heahh k Safety Code,Sections 25505,25533 and 25534. I
understand that if the building does not Currently have a tenant,that it l.my NEW RESIDENTIAL MECH. SQ.FT.
respmalbility to notify the occupant of the requlmoants which must be met
prior to Issuance ala Certificate of Occupancy. _ 4♦�J -
' Owner or authorised agent - - -, Date' TOTAL - ISSUED BY:
. OFFICE COPY