21832 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
s
Building Proen Identification PERMIT NO.
Bulldinss: 218 3 2'
ag Addree t uo �� ..
n ant,ef: one A A A
s A.lZ �-7 CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lk.Na APPLICATION /.PERMIT
Lic.No: BUILDING-ELECTRICAL -MECHAMCAL CATEGORY CONTROL#
Archil-ct/Efiglireee
QTY - ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1T� Nil
LICENSED CONTRACTOR'S DECLARATION •I� ��I
I hereby affirm that l am licensed under provisions of Chapter 9(comment. APPLIANCES-RESIDENTIAL JOB DESCRIPTICIyy
inense1Semon fore)andefelon3o(the Busineuand Professions Code,and my ^ n �+0 IQ
license k in Tion force and effect. PANELS
�•a FTL II L
License Class Lk.p
Date Contractor —UP TO 200 AMPS
ARCHITECTS DECLARATION 201-3030 AMPS
Z I understand my plane shall be used as public records. OVERIOXIAMPS SQ.FT.FLOORARFA 5/SQ.FT.
00
Iy (Cj Licensed Professional SIGNSELECTRICAL IN
GG Q OWNER-BUILDER DECLARATION
fit Fn SPECIAL CIItCNT/MISC Q
y., 7 IherebyalArnthat lam exempt from the Contractor's License law forthe 1 a
ZO O Q following reason.(Se tion 70315,Business and Professions Code:Any city or Tp�{p.METER OR POLE INST. no W county which mqulresa permit to construct,alter,Improve,dennlish,or repair
anystruture,prior to its issuance,also requiresthe applicantfor such permit toPOWER DEVICES
F1 O file a sued statement that he is licensed pursuant to the provisions of the
t; Contracime License law(Chapter9(comniercngwith Section 7000).fMei. SWIMMING POOL ELECTRIC DATI
X05 sion3ofthe Businessandlr mior Code)orthathebemmptthemfmmand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIiFSFIXTURES /1 eQ�o—`V
<�
applicant civil ntfora permit subjects the applicant to a il penalty of nmothan `'�')V
o Ave hundred dollars($500). NEW RESIDENTIALELFCIR 'SQ.FT. STORIES TYPE CONSTRUCTION'
❑I,as owner of the property,or my employees with wages as their sok
7.Q, compensation,will do the work and the structure is not intended or offered for
p sale(Sec.7044,Business and Profession,Code:The Contractors License Law
3 docs not apply to an owner of property who builds or improv,thereon,and OCC.GROUP RES.UNITS
who does such work himself orthrough his own employee,provided thatamh
improvements are not intended oroffered forsals.I(however thebuliding or TOTAL:
Improvement o sold within oneyearofcompletion,the awnenbudderwlll have
t rden of proving that he did not build or improve for purpose of sale.). QTY. .PLUMBING PERMIT FEE F[AOD ZONE - APN .
owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE eZ`(�
tra ors to construct the project(Sm.70K Business and Professions Code:
Contractor's License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon,and who contacts for such pkojects with a FEE SUMMARY .
o,6.ctm(.)licensed pursuant to the Contractor.License Law. gACK PLOW PROTECT.DEVICE
L,J I am exempt under Sec. B &P C for this re
OUTSIDE FEES
acon DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date re RFCEII'T#
'WORK MAN COMPENSATION DECLARATION pD(TURES PER TRAP (�^ SCHOOLTAX Y_ N
❑i hereby affirm that I have o certificate of consent to py the or RECEIPT#
certificateC.Workers Compensationln,urance mracertilled copy lheteof(Sec. GAS FA.SYSIM-1 INCA OUTLETS PARK FEE Y_ N
PolicM00,y
lab CJ RECEPT#
Polity# GAS EA.SYSITM-OVER 4(EA)
Com ny BUILDING DIVISION FEES
Certified copy is herebyfurnished.
❑Ccrtifid copy V filed withhthe city
inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM CA.]OOFT. Date Recef I#
(Ihissetion need nor be completed if the permit Is forom hundred dollars
(5100)orless.) - WATER HEATER W/VENT/EdFCTR. ENERGY FEE Y N
I certify that N the performance of the work for which W issued"s permit is issued"
I shall not employ any person in any humor»as to become subject to the WATIR SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.F. Dale Recei [#
Z O NOTICE TO APPLICANT:If,after ma king this Certificate of Exemption,you
should bemme. ns
ubject to the Workers'Compensation provision,of(he Labor TOTAL:
fD Code,you=at forthwith comply with such provisions or this permit shall be
LU > deeBUILDING FEE X�
med revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE L
CL Iherebyaffirenthat there is a coneurecion lendingagency forme petorm�
dELECTRIC FEE
M Z ante of the work for which this permit is Issued(See.3097,Civ.C.) TOTAL: s
02 Lender's Name PLUMBING FEE
LL f dor
fea Address - QTY. MECHANICAL PERMIT FEE
U 1certifythat l have read this applicatlonand ve statethat theaboinformation - ,��w MECHANICAL FEE ���•
O W urr
coect l agree to comply with all ttyand county ordinances and state laws PERMIT ISSUANCE ,ZCZ FEES PAID:
} 4 relating to building construction,and hereby authotee representation ofthis
F N city to enter upon the above-mentioned property for Wpecron purposes. ALTER OR ADDTO MECH.
Z Date Receipt#
(We)agree m.ave,judgment,
fly an d keep es whitharmless the City of Cupertino
against liabilities,judgments,cosband expenses which may In anywayaame AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
eignalureof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or nandle ha:amous HEATING UNIT CFO 100,000 BN) Date Recci t# _
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the /
Ilealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes IM No
Willtheapplicant or future building occupant use equipment or devices ' VFNTILATIONFAN(SINGLERESID) L{L sp I W&CE DATE
which emit havndous air contamimnts as defirmd by the Bay Arca Air rQp
Quality Management District? BOILER-COMP QHP OR 100,0(*BTU) tiY 1 p tax
Yes ❑❑No ! 3 1Y4O
4heve read the hrzardfnt m.dr,.s i.0 requirements of BOILER-COMP(OVER 100,000BN) AIA
# �(�
the Gltfomlaat if th&6a(eIy Code,notions 75505,ve a t and 25534.1a. a�{
undeoitand notify the occupant
oche currentlyhavetenant,that In,is Mymot NEW RESIDENTIAL MECH. SQ.FT. r(Q/#kta.a
r,poto Issuance
c of notifytheof Ocftherequiremente which must be met WIC/_�?nt
prior to issuance ofaCcrtificate ofOmpanry., - V
Owner or authotud agent Date
TOTAL: ISSUED BY_
OFFICE COPY