21121 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building AddreBuildin Project Identification 0 Z P' TNO.
X03 b a PLrt� 21121
nen assn: p one:
_HbZZRWZ C}QQtJp CITY OF CUPERTINCLBUILDING DIVISION
• Coromn°raName: �• APPLICATION /PERMIT
,
rohC/^ BUILDINGELECTRICALPLUMBINGMECHANICAL l CABYCONTROL Y
�' � C Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRFITISSUhNCE �'
thereby
hb 'LICENSED CONTR SDECON , 1 � Ln
$
that munder provisions
ofChapr9c APPLIANCSRFS7DENML
ingwlthsctOA7000)ofDivi.i.3.itheBu.] essandP (essionaCodeandoJOB DESCRIPTION
license is In funand effect. L
PANES S FOWL-
a Lic,Y,
D.te3t C,mtrad.r_X/za_1_
ARCHITECTS DECLARATION 701-1000AMIN
p�p�uuQ7: I understand my plane shall be used as public records. OVERIOOOAMPS SQ.FT.FLOORAREA $/SQ.FT.
6:0 Licensed Profeeelarul SIGNS ELECTRICAL
6 OWNERBUILDER DECLARATION SPECIALCIRCUIT/MLSC "/,' p•�r.
Ihereby allrmthat lamexempt from the Contractor's License Law for the , I C hes IYI1
following reason.05ectlon 70313,Business and Professions Code:Any city or O i. TEMP.METER OR POLE INST.
P� muntywhich requires a permit[omrutruat,aller,lmprove,d<nnllah,orrepsir
anysimeture prlorlo its issuance,also requirestheappliant fonuch permit to POWER DEVICES
ilk a signed statement that he k licensed pursuant to the provisions of the
Contractor's License Low(Chapter 9(commencing with Section 7000)of Divi- SWAIMING POOL ELECTRIC
.;7.1 elon3 ofthe Business and Prolesslom Cade)orthat he b exempt therefromand
VALUATION
0 the basis for the alleged exemption. Any violation of Stolon 70313 by any �►
appUmntfora permit subject/ OVILEISSWIIOHESFIXNRES the applicant to a civil penalty olnut morethan 18L+ qIo
liv�e,�undrcd dollen($500). NEWRESIDENTIALELECTR SQ.FT. W
�n u I,as owner of the property,or my employees with wages as their sok STORIES•! I { TYI'ECONSTR11CT10N
compensation,willdothe work and thestruciure is not intended or offered for
Qsale(Sec.7044,Businnfessu eand ProimCode:The Contraciare License Law
L�
E�F docs not apply to an owner of property who builds or improves thereon,and OCC.CROUP RPS.UMTS
E who doessuchwork hlmselforthraugh Meownemployees,pros•ided that such
improvements are not Intended mafferedforsale.If,however,the building or TOTAL: ('
Improvement bsold withinomyearofcompletion.theowner-hulderwllluve
ttrIiurdeno/proving that he did not bund or Improve for purpose ofuk.). QTy. PLUMBING PERMIT FEEF77.00D ZONE APN
LI L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec 70K Business and Professors,Code: PERMIT ISSUANCE Pl
The Camnn ctor's License Law donot apply o an owner of property who ALTER-DRAIN&VENT-WATER(EA) r La
Wild.or Improves thereon,and who contracts !or such ptojecfa with e
co,pt1aetor(s)licensed pursuant to the Contractors License Law. RACY FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See B k P C for this reason
•
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N RECEPTY
WORKMAN COMPENSATION DECLARATION FDnIJRM PER TRAP SGICK)LTAX Y— N_
hereby affirm that I have o lrt cone of consent to epytheure,ora RECEIPT Y
3900,abo(Worken'Compenutlonlrounnre ma artlled copy thereof(Sec. GAS 4 PARK FEE Y N
380Q Lab CJ FIN fu—TF D TW
Polity p RECEIVE p
Com any AlCV d BUILDING DIVISION FEES
On
copy b hereby furnished. GREA IN s I Er R PLANCFIECK FEB
❑Certified copy b filed with the city Inspection division. ��f
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE�1 WM l pAlp
FT_
COMPENSATION INSURANCEaaaass
(This seSEWER-SANITARY-STORM EA 200FT Date RC i t# I `••y
ssineed nabs ot be completed Rthe permit V(orone hundred dollars
(f100)orle WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(cethat that in the performancealthework forwhlch this permit leked, —
I shall nm employ an/person In any manner w n to became wbjed to the WATER SYSTEM/TREATING
z
Workers'Compensation Laws of California -Applicant NEWRESIDENTIALPLMB. SQ.FT. Date Revel t#
Z 0 NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
Code,you
subF with co Workers'such pro islo pmvbiow permit
shall
TOTAL:
W Code,you moat forthwith comply with such provkloro orthla pemdt shall be �'
BUILDING
FEE
j deemed revoked.
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z IhercbyafBrm that there ba construction lending agency for the perform TOTAL: ELECTRIC FEE Q
anwottheworklarwhkhthbpermitbLt d(Sec.3097,CIv.C.) C.1 1
U O Lender's Name PLUMBING FEE O
u. I.endcra Addre QTY. MECHANICAL PERMIT FEE MECHANICAL FEE d Q
OW 1 certifythat I have mad thisappliatonand statethat theaboveinformation p� a
1 Is. ot.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE a-Rl FEE-PAID:
} W relating to building construction,and hereby autharlae representatives afthk -
1— Z city to enter upon the above-mentioned property for impaction purposes, ALTTRORADDIOMECH.
(We)agree to Atyan p harMom the Clty of Cupertino Date RLYeI I#
against llablllt st pen ewhkh may In anywayacome AIRITANDLINGUMT(TO10,000CFM) SUBTOTAL:agams ty In egn ngofthispermit AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
o !�'D
gnaturc of ant/Contractor to IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DIS 5 6
Will the applicant or future building occupant store or handle hazardous HEATINGUNIT(TO100,0001HIJ) Da[e RCCeI t# � Se3rI )
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the -
Health and SafetyCode Section25532(a)? HEATING UNIT(OVER 100,000 RTU) TOTAL:
❑Yes In No
Will the a pplicant or honors building acv pant use aqui preen or device VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haaardous air contaminants as delved by the Bay Area Air
Quality Marugcment Diaoict7 ROLLER-COMP OHP OR 100,0(0 BTU)
7 yes n No prsrs
have read tech&he a et Cods brequlrcmenb5533 aChapter. 1Sof BOILCR-COMP(OVER 100,000 BTTJ) Dy
the California Health&Safety Code,SeRloro 75505,]5533 and 7SS34. I '
understand that Uthe building does not comently have a tenant.that It is my NEW RESIDENTIAL MECH. SQ.R pppp,�4 tlJ��
nepomiblity to notify the occupant of the requlrcmenlewhich must be met ••4 fist 4U yy
prior to issuance of a Grtlfiate of Ompanry. �
Owncrorauthcrized agent Data " `• 9.•y�.i
TOTAL: Os
ISSUED BY:M& Y's•�1
OFFICE COPY