21544 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldemUl¢tlon r- PERMIT NO.
IBding d¢,,: 21544
-\\ nen one:
J ` (� UA CITY OF CUPERTINO-BUILDING DIVISION • I // nr
Utra .Na : LIp.No: .APPLICATION /PERMIT
BUILDINC ELBCTWCAI PLUMBING.MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lle No:
_ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add..]S, - J
PERhtITISSUANCE ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that l am licensed under provisions of Chapter9 taingramc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwllh5ectio 7000)mL vlalon3 he0ucincss nd ProfculaneCode,and my
license I.In ( defect. �' ' // PANELS
Lima
Dale if/(II-talf`n11,_ Contractor -
ARCHITEC ATI 701-1000 AMPS
PO+
NZ
I under emi my pbta shallbe used as public records OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E U Licensed Professional SIGNS ELECTRICAL
In 6 OWNER-BUILDER DECLARATION SPECIAL CR2CNT/MISC
Z �4 herebyaffimthatlamcxemptfromtheContractor'sLicenseLawforthe
oo popp following reason.eiroilpn 7031.5,Business and Professions Cade:Any city or
FZ~ cwntywhkhrcquimsopemdtWmmtmcl,aller,lmpmve,demolbh,orrcpalr TEMP.METER OR TOLE 57.
anystncture pd¢m its Issuance,also requlnstheappBant for such permit to
file a signed statement that he is Itomead pursuant to the provisions of the POWF.RDEVICES
OOH Contractor'sLicense Law(Chapter9(commencingwlth Section7000)ofDlvl-
3 sion3ofthe Buainessand ProfenbruCode)orthat helsemmptthe¢fromand SWIMMING POQ ECTRI VALUATION
W S the barb for the alleged exemption. Any violation of Section 7101,5 by any
< applicant fora peremisubjects the applicant to a civil penalty a nut mare than OLTTLE`ES.SW/C��FIF6ES
lWe hundred dollars($500), NEWR ENFA EC SQ.FT. STORIES M'E CONSIRIK:TION
�n ❑I,lie owner of the property,or my employees with wages es their sole -
compensation,wllldothe work andthestructure b not Intended lir offered for
0 sale(Sec.70K Bualnessand Prefen(ars Code:The Contractor.Lt¢rue Law
docs not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
0.0.0. whod...ch workhimselforthrwghhisownemployeee,pravidedthatsuch
Improvement are not Intended proffered forsale.IL however,thebuilding or TOT
Impmvementbaotdwithinomyearofc¢nplctWmtheowner-bu0derwlll have _
lrW-purdenof proving that he did not build or improve for purpose ofubJ. QTY. PLUMBIff
MIT FEE phDDO ZONE ppN
LJ L as owner of the properly,am exclusively contracting with licensed PERMIT MF f9gUpNCE
contractors to construct the project(Sec.7014 Business and Professions Code:
The Contractor'.Limn¢Law don not apply to an owner of property who ALTER-DRAIN As VENT•WATER
Wilds or Improves thereon, and who contracts for such Enplem with e
�gp{factor(s)licensed pursuant to the Contractor's LI¢nm Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,CO SANITARY Y N_
Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FMTURES PER TRAP SCHOOLTAR Y_ N_
I hemby af(Irm that I have a¢MOeste o!consent to self-Inure,¢a RECEIPT#
ceFlBcatea(Worken'ComppeevatlanIreurance ora certified copythercot(Sec. CAS F.A.SYSTEM-1 INC.40UTL PARR FEE Y N
3BOq Lab C,) 1I'/\��fnn777 �7 /a
Paltry# �� ,G BBCEIls7'#
Coman furnished.
- GAS EA.SYSITM-OVER��— BUILDING DI VISION FEES
[PCertlfi d copy rcby fu lehed. CREASE/INDUS IM,WA NTERCEPIOR PLANCHECK FEE
�rtlfied copy is filed with the city Inspection division.
CERTIFICATE OF E)(EMPTION FROM WORKERS• GREASE TRAP PAID
COMPENSATION INSURANCE
(Thbaecti,mmed not becompl&cd B the permit bforomhundreSEWER-SANRARY-
d dollars RM EA.XpFT. Date RCcai t#
($100)prl¢e.) WATER HBA /VENT/ELECTR ENERGYFEE Y N
I certify that N the performance of the work for which this permit is bored,
I shall not employ any person In any manner so as to become subject to the WATER SY /TRBATTNG
Worken'Compensatlon Laws of California.Date PAID
O Z Applicant NEW OFNIIAL PLMB. SORE. Date RCCCI t#
Z O NOTICETO APPLICANT:If,after making this Cerllfirateof Exemption,you
Hshould become subject to the Workers'CompemaHon pmvisiomafthe Labor TOTAL:
fn Code,you moat forthwith comply with such provisions orthb permit shall be
> deemed revoked. BUILDING FEE
a � CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of@m that there Is a construction lending agency for the performELECTRIC FEE
(be
L)= O once of the work for which this permit is Issued&c.3097,Civ.C.) TOTAL PLUMBING FEE
Lender'.Name
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W ]artlfythall have read thbappliatbnand A.tethattheabove Information
bcorrect.]agreeta comply with all cttyand county ordinance and elate laws PERMIT ISSUANCE FEES PAID'
} a relating to building construction,and herebyauthonae rep oemaUve pfthb
(— Z city to enter upon the above-mentioned property for lv on purposes. ALTERORAODTOMECH.
— (We)agree to save,Indemnify an d keeph
harmiex the ity f Cupertino Date ReCelPt#
agabutl Wtin,' dgmenb, sand expenses which to ,ayamue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
against con o(the granting of this it
// AIRHANDLING UNTT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of ppllcant/Contract oat F7(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DIS LOSURE
Will theappllanl or future building occupant store or handle hanrdous HEATING UNIT(TO 100,ODO RTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date ReceI t#
Iicelth and Safety Code Section 25537(s)? HEATING UNIT(OVER 100,000 STU) TOTAL:
F1Yen No
Wllltheappliant or Nrs building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit haurdoua all conlamirunt a defined by the Bay Area Air
silty Management District? BDELFR-COMP OHPOR 100,000 BTU) it fllti d B 1`JJI
Yea ❑No
harHealth�bh
ardoue mode,Sections
e regWmmpnbundeand ZS5 4. I of BORER-COMP
the Californiatandt Health k Safely Code,Section29505,ve a land that it
t
respunderatandy to If notify
the occupanng doest
of
errently equirgn,me which
that It mets my NEW RESIDENTIAL MBCH. SQ.IT.
raporolbluty ce of lfy the occupant of the nqulremente which moat be met
prior to issuance ofa Certilkate a(Occvpanry.
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE COPY