21415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Pro'ed Identification PEIiMITNO.
Building Address: - 214 11
5
21-7-71 LOM lT
In e ante: ane: A A A
mer ♦ CITY OF CUPERTINO-BUILDING DIVISION t_l9/ q
cmntrador',Na ye.No: APPLICATION / PERMIT ^-L'�
�jemlJN 3SL6Ly Z BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLM .)p./1
X
�. Archit /En r. /k.No: GOO...l
QTY ELECTRIC PERMIT FEEBUILDING PERMIT INFO
Address:'Z,409f}�PL -S-1— PERMITISSUANCE 1db b ULLI PLUMB
MEC
LICENSEDCONTRACTOR' Df~ IECLARATION �[f & X
Iherebyafftrmthat l am licensed under provisions of Chapmr9(commme- APPLIANCES RESIDENTIAL JOB DESCRIPTION
Ingwith5ectiun 7000of Dlvis(on3ofthe Busimmand Pmlessions Code,and my a
license is In full( and effect. PANELS
License-�y � Lic.p
Date Contractor 201-1000AMPS
ARCHITECTS RATION
otOz [understand my playsluB be used as public record,. OVER 1000 AMPS SQ.FT.FLOOR AREA $/:Q.FL.
odC° 2�d1
(0 Licensed Professional SIGNS ELECTRICAL
a 1
Esu OWNER-BUILDER DECLARATION
7
rn � L1LCEiCUfT/MISC IherebyalRrmthatlam exempltromlhe Contractor's License law for the Z 1 l 1
following reason.(Section 7031.5,Business and Professions Code:Any city or
O f:� TEMP.METER OR POLE INS(.
�pp cauntywhich requhes a permit to construct,alter,improve,de=lBh.ormpair
Fy .'si
an
ystromire primm its issuance,abas require,theapplicant for such permit to POWER DEVICES
C e.U file a signed statement that he is licensed pursuant to the provisions of the
Orsi.. Conirador',License Law(Chapter9(commencing with Section 7000)of Divi- VALUATION
GG11 �n SWIMMING POOL ELECTRIC
F, OS sion3olthe Business and Professions Code)orthat Febexemptthercfromand
the basis for the alleged exemption. Any violation of Section 70315 by any M OUTIRTSSWITCIiESHXTURFS
applicant fora permit subjedsthe applicant to a civil penalty of nroom than `1 a
o five hundred dollars($500.
NEW RESIDENTIAL ELBCTRSQ.FT. STORIES TYPE CONSTRUCTION
I,as owner will
the property,or my employees with wages r thele sole
kzG compensation,Business and randthesCde:TheCntracture is cut edoronse,d for
Law 'l
5 D sale(Sec.apply
Business Profession Code:The or improves License Law d
docs not apply torn owner ofpropertywho nem oy mprovnthereatand
p'$^
who does such work hlmxltorthrwghhis ownemployees,provided that such R RES.UNITS
Improvements are not Intended orolfered lorsale.If,how n co,thebullding or TOTAL:
Improvementbwld withinmayearof<omplMion,the owner-bu0derwlll have
thLLveden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE F[A APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ronfractors to construct the project(Sec.7014,Business and Professions Code: 4 cc
-
The Contractor's License law doe,not apply to en owner of property who ALTER-DRAIN&VENT-WATER(EA)Wilds or Improves thereon,and who contracts for such Iopjects with a FEE SUMMARY
<g0[(actor(s)licensed pursuant to the Contractors License Law. BACK FLOW pROT[CT.DEVICE
LJ I am exempt under Sec. B &P C for this reasonOUTSIDEFELS
Owner Date DRAINS FLOOR ROOF,AREA,CONT. SANITARY Y_ N_
RECEIPT X
WORKMAN COMPENSATION DECLARATION FO(Tl1RES PER TRA[' SCHOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT— NX
rertificate of Workerv'CompensationlnsuranmmaartiBed ropythereof(Sec. GAS EA.SYSTEM-1WCAOUILETS PARK FIE Y N
3800,lab C, ry� RECE PT X
-- Po11cyX GAS�FA.5YSITM-OVER4 LEA)Com BUILDING DIVISION FEES
�Cenified copy b hercbyturnlshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�ertNed ropy b
filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID o [
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date Recd Ut 7�trsa
�
(1'hissedion need not be completed Behe permit b(oroa hundred dollars
($100orWATER HEATER W/VENT/EI-ECTR ENERGY FEE Y_ N_
[certifyfy that Na
the perfonn<co(thework for which this w
Permit i,leaned,
I shall not employ any person in any manner w u to become subject to the WATER SYSTEM/TREATING
Workers'Compenwon
tlla.m Califomb. Data PAID �'
O Z Applicant NEWRESIDENTIAlPIMSQ.FT. Date RL'CCI Fk (OS)t� `
Z B.NOTICE TO APPLICANT.If,after making this CertBivteof Exemption,
Hshould become subjeet to the Workers'Compensation provisions of the Labor ^, TOTAL:
W Code, must forthwith comply with such provisions or this rmitshall be x
S j deemed revoked. P r P Pe BUILD NG FE t
W - CONSTRUCTION LENDING AGENCY SEISMIC FEE '3b
d Z I hereby,affirm that there b a construction lending agency for the perform- TOTAL: /1yy�y �. ELECTRIC FEE sC�
aoneottheworkl hl 's, we e3v97,Civ ) -I 'x
00 lender,Name ! PLUMBING FEE q TIC:v
LL I- Lander'sAddrcss �AR % QTY. MECHANICAL PERMIT FEE MECHANICAL FEE L
OW I certifythat l have read f applicafWnand katethauheabove information 4-.�
1 is correct.l agreem comply with all cityand county ordinances and state laws PERMIT ISSUANCE MQ0 FEES PAID:
} relating to building construction,and hereby authorize representative,ofthis
F N
city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReeciptM
V against liabilities,judgments,costsand expenses which may In anywayaoous AIR HANDLING UNIT(TO III"CIM) SUBTOTAL: _
,gelnst in conuquen o(the granting of this permit AIRHANDWNGUNIT(OVER10,000CFM) CONSTRUCTION TAX -1
` /�j� EXHAUST HOOD M'/Duch CONSTRUCTION TAX PAID:
SI //Contactor Bate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Reeef tp
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Codr�ioa 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL: Z�
OYet Lwjw.
W the a pplica nt uE future bu ilding occupant use cqui pment or d evices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Du ittT BORER-COMP OlB'DR IW.IXD BTU)
EM it.
hazardous BOILER-COMP(OVER 100,ODO BTU)
the California Health&Safety Code,Sections 75505,75533 and 25534. I HA11!�]
understand that lithe building does not currently have.hoard,that It b my NEW RESIDENTIAL MECH. SQ.FT PAM
tvporogblllty to notify the occupant of the requirements which most W met -YLCD
priof}a-® ace ofaCerti'ate of Occvpanry. 3a•u•� p 499•
001re'r or authot dagent C DaleISSIIEDBY:
TOTAL: -a Yx� tai,.
OFFICE COPY
i