21824 (2) APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Idrmi(latlon PERMIT N218 2 4
Building Address:
Jl
n one: MIITICA I ION SUbMITI AL DA
a� CITY OF CUPERTINO-BUILDING DIVISION
c° trayar'a me. Lic.No: APPLICATION 1 PERMIT
BUILDING-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROLx
Artium/Engineer. tic No:
BUILDING PERMIT INFO
(27Y ,-��s^*r ELECTRIC PERMIT FEE'
Add. PERMITISSUANCE ❑ ❑ n ❑
LICENSED CONTRACrOR'S DECLARATION �J
I hereby affum that l am licensed under provisions of Chapter 9(commenc, APPLIANCES RESIDENIAL JOB DESCRUMON
ingwith 5ection7800)ofDiWsion3ofthe Buaineuand Professions Code,and my d �G. . , ;�SQ
Itcense L re in full faaneffect. PANES FKJ L
Limas Claus LieM
Dale Cmdrarmr UP TO 200 AMS
ARCHITECTS DECLARATION fill-IOW AMPS
I or I understand my plane stall be used as public record& OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
:b� Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFLIALCIRCUIT/MISC
I herebyaftl
firmat I amexempt from the Contractor's License Law for the
to reason.(Brother,7m15,Business and Professions Code:My city or
H TEMP.METER OR POLE INST.
muntywMrhpe t-iapermutomrohuct,alter,imph.tfonWh, er ter
S anyrtrnaure tate mitshat he I Jimmied pursuant
t the mreuchprovisions of t e pO(WER DEVICES
file' Co a aimed statement that he t rg(mxm pursuant m the ficin700) of the
Contactori Lcense Lw(Clupter9(mmnendngwlth&Mon 7000)ot Divi- SWD04NG POOL ELECTRIC VALUATION
O uon3ofthe Butl m=dProfesiem Code)orthatheleemmptthemfmmand
the basis for the alleged exemption. My ,violation of Seckm 7(EI5 by any OUTLETS-SWITCHF&FIXTURES
applicant fees permit subjects the applicant to a civil penalty a not room than
9 five hundred dollars(5500). NEW RESIDENTIAL E.ECTR FI.
STORIES TYPE CONSTRUCTION
❑I,a owner of the pmperty,or my employees with wags ae their sole '
-co compensation,will do the work,and the structure is notidended or offered for
r-O ale(Sm 7014,Business and Professlam Code:The Cmumm h Lcense Law
$ doesnotapplyto an°water of property who builds or improve,thereon,and OCC.GROUP RFS.UNITS
who dos such work himself orthrough his own employees,provided that such
4nprovemens are rwt intended oroffered for sale.If,however,thebuildingor TOTAL:
Improvement is Bold within oneyearofcompletion,the ewner-builderwW have taw
en of proving that he dm not build or improve for purpose of sale.). CITY. r, e,',`�;�PLUMBINGPEBMIT� :" '`�:iFEEI'i FLOOD ZONE APN
owner of the property,am exclusively contracting with licensed
anutes to comment the project(SM 70th,Business and Professions Code: PERMIT ISSUANCE
E IZe�
Coruscior's License Lw does net apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or improve thereon,and who contracts for such ptojma with a
ogBtr+otarW Licensed pursuant to the Contsoto/s Liens Law. BACK FLOW PROI'FLT.DEVICE : .FEE SUMMARY'_a's.
LJI am exempt under Bee B k P C for this reasonOUTSIDE FEES
OwnerDrte DRAINS FL.ODR ROOF,ARCA.COND. SANITARY Y_ N_
RECEIPT«
WORKMAN COMPENSATION DECLARATION
C31 hereby affirm that I have a certhfiote of consent to aeB-weer,e a FIXTURE(PTR PRAT SC[i00L TAX Y N
mrtRioteof Workes'Compensation Insurance oract rtif ed ropythereed(Sec. RECETI"C M
3800,Ieb CI GAS EA.SYSTEM.1 INC40I1TI.E 15 PARK FEE Y_ N_
R
Policy M ECEEPT jGAS EA.SYSTEM-OVER 4(EA)
Com ey BUILDING DIVISION FEES
❑Certified copy b hereby mr he city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V Ned with the MY inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CRkm TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFT Date Recel t#
CI'hlsseRion need not be completed Bihe permk V(Drone hundred dolian
($t03)mleWATER HEATER W/VENT/ELECTR
IforlessENERGY FEE Y N
.).) 0the perlomunceo(thewmkforwMchthis pemdt is Issued,
I shall not employ any person in any manner an u to become subject to the WATER SYSTEM/TREATING
Workeri Compensation lAws of Calfternla.Date PAID
Z ApplicanNOTICE( NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
O NOTICEco esubjettothe Workers'
makiomensation pro ofExempt.,of
,you
should become subject to the Workers'Compensrtlon provisions p of the Labor TOTAL:
N Code,you rrwst forthwith comply with such provisions orchis permit shall be U
j dsemed revoked.
C
CONSTRUCTION IIv DING AGENCY SEISMIC FEE
Z Therebysorters WtiherebammtsRlonlendingdCSec. agency Civ. .) perform ELEC'T'RIC FEE
arm afthework forwhlch this permit biuued(Bee.3097,Civ.C.) TOTAL: (',�'
O Leaden Nana PLUMBING AL .C.�
F Lenders AthatI QTY. '! .:".MECHANICAL=PERMIT:-x . FEE. MECHANICAL FEE
O omd.I daubs e madcompl MaapaLiati and murty ordinances eInformation
W
bctingto agreeto cemmuctioh allcityhumb auhemee ordinances and gate laws PERMIT ISSUANCE FEES PAID:
W relatinglobuilding ronstruRlon,and hereby autherize representatives of this
Z Rey to enter nthc abovemenlioned property for lnspmlon purposes. ALTER OR ADDTO METH. Date Receipt#
c e e,indemnify an d keep harmless the City of Cupertino
agai I tie dgrrcnts,cosh and ex swhlch may In anywayaccrue AIR HANDLING lINR(TD 18,000 CFM) SUBTOTAL:
agai { as
it,t on xcluenre o(thegadti fthisperm . CONSTRUCTION TAX
1 AIR HANDLING UNTr(OVER 10,030 CFM)
igna p1lnt oma PNN
Date AUSTHODD(W/DIR:D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUR EXFI
WW the appllardorfuture building occupant store or handle hancedous HEATING UNIT OO 100,003 BTU) Date Recei t#
material as dell red by the Cupertino Municipal Code,Chapter 9AZ and the
Healthand Safety Cede Section 25532(+)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ys No
Wfiltheappliard cur ms building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haeardous air.mnsmWnb as cleared by the Bay Area Air
slily Mansgwreset D(strlci7 BOILER-COMP OHPOR 100,004 BTU)
i�J Ys Q No
lhave mIdthehvardouemalerialsmquiesment,un derChapterb.95of' BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Stolons 25505,25513 and 25534.1
understand that if the building dm net currently have a tenant that it is my NEW RESIDENTIAL MECH. SQFr. C Y
rspaumDRy to notify the eceepent of the requirements which=at be,tree
.'prior to issuance of a Ce dilate of Occupancy. ru �
Owners authorized
d agent' Date ISSUED BY:f'
TOTAL-
OFFICE
OTALOFFICE COPY .