21601 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PE N F
B,lMin g Pmlect Identification - .thIT NO.
Building Address: O.
7 Alv!E 21;5-1 21601
tie ansa: one.
CITY OF CUPERTINO-BUILDING DIVISION
conhattora Name: LIo No: APPLICATION /PERMIT
BUILDING-ERCTRICALML BING MIGHAMCAL CATEGORY CO
Archietectt/E glneer. - Llc.No: '
1N I] �NY� `-- - ' -'� BUILD_ ING PERMIT INFO
C� ^,1�A��s1�� y ( QTY ELECTRIC PERMIT ,, ,FEE
Address,*&W P_s LPI'l1 tzaaN_ Av a $ IPE WTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirtn that l am licensed undei provislonsof Chapter 9(comment, APPEANCESRESIDENTIAL JOB DESCRIPTION
ingwith Se on7000)ofMWision3ofthe Bustnemand Prolemlon.Code,andmy Q �N
license Is In full force and effect. PANEL4 - - Pro U
License Clam LIc.N I' S
Date Contractor up 101121AMM _
ARCHITECT'S DECLARATION 201-1000AMPS
Iq+�Q 2 I understand ery plans shall be used aspublic records. OVER 1000 AMPS -SQS/SQ.FT:
E lyj' Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
fn a SPECIAL CIRCUIT/MISC
owing attermthat Tam313,B fromthe d Profession.Code:
Raw fort he
pp ocy following reason.(Section 78115,Business and Profemlone Code:Any city or 3 6
021:3counmpair
TLMP.ML'fFR DIPOLE INST: S
�� anysty Mmpdofch ltolftmsapermitce,ansmquimsthetruct,alms,mprovntfor lbh,erfttto ,
�[ any atrudurepaterfelts Issuancee alcensed pursuant
to the eavisthperMte POWER DEVICES / �y
K file a signed statement that he ter9(commencing
pursuant it the t..7000E of the
Con3ofthe usffieLicensind Proewio Cm e)orthathe with mpt hemfml and SWIM IANG IDOL ELECHUC VALUATION
s, OJ elon3ofthc Businemand Pro(emioru Code)orthat hebexempttherclromand
�.'•3 the bash for the alleged exemptlw. Any violation of Section 7031.5 by any OUTI'E7SSN7TC7iFSF1%'MtFS Map
applicant for.permit subjecta the applicant to a civil penalty of no than
ot m
E five hundred della.(¢500).
❑I;as owner of the roc NEW RESIDENTIAL ELECTR' SQ,7. STORIES TYPECONSTRUCTION
p p rty,or my employees with wages ea their sole
ZpQ compensation,will it o the work and the structure is not Intended or offered for
FD sale(Sec.7044,Business and Professions Code:The Contactoes License law
does not apply to an owner of property who Wilds or improves thereon,and assisit
R
EE who does such work himself or through his own employees,provided that such tip
improvement...otlntendedorofferedforsale.If however,thebuildingor - TOTAL: L
Impmvemont issold withinuneyearofcompletiagtheowner-bu0derwill have
Ie idenof proving that he did net build or improve for purpose aleakJ. QTY, ,;;I � �,PLUMBING'PERMIT,:
as owner of the property,am exclusively contracting with licensed ' l PERMITISSUANCE 1^1`� /g
fracture to construct the project(Sec.70K Business and Pnef estom Code: .0
The Contractor's License Law dues not apply to an owner of property who '
Wilds or Improve thereon, and who contracts for such pRopALTER-DRAIN&VENT-WATER(EA)cts with a i
cgy((actor(s)Icesed npunuantrothe Contraetor'e License Law. �„ :'�It FEE,SUMMARY.�
LJ I am exempt under Sec' B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FEITURES PER TRAP SCHOOL TAX Y_ N
01 hereby af(Irtn that I have a certl0ate of consent to ee0-Inwm,ora •� RECEIPT R
certificate olWorkere Comperuatlonle,orance or a certified ropythereofelee. GAS F.A.SYSTEM-1 INC.40IJILLTS
3800,Lab Cd - 2�Q6 PARK FEE Y_ N
Policy N I RECEIVE q
Com an CAEA.SYSTE -OVER4(EA) -
Y S M
BUILDING DI VISION ETES
Certified copy is heed with the
city i GREASE/INDU5ML WASTE INTERCEPTOR PCANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200F1'. '�•'Date Recei t 7�
(Th is section neetl eat Wcompleted lithe parmltt.for one hundred dollars
($100)or WATER HEATER w/VENT/E.I:CTR ENERGY FEE Y-' ` N
(certify that In the performance of the work forwhich this permit is
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING M
workers'Companaation Laws of California. Date PAID y, ,
'O Z Appllant NEW RESIDENTIAL PLMB. SQ.F. Date Recei t# L'_N
Z O NOTICE TO APPLICANT.11,after making this Certificate of Exemption,you 4
should ecome subject to the Workers'Compensation peovislonsolthe Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be dad
deemed revoked. BUIL G 7 J
WCONSTRUCTION LENDING AGENCY SEISM IC FEE t
a I hereby affirm that there Is a construction lending agency for the perform I� ELECTRIC FEE
M Z anceofthe work for which this permit isIssued(Sec.3097,Civ.C.) TOTAL: jQO q,
O O lender.N. PLUMBING FEE ®Q
LL F tenders Address QTY.. � 'MECHANICAUPE'RM'1T*,',' FEE ' MECHANICAL FEE 0
O W I certitythat l have read thisappllcattonand slatethat theabove info m tion �•'4
1 iscomect,I agree to complywith all city and=my ordinances an d, tet.w. I PERMUISSUANCE L � FEES PAID:
Yrelating to building construction,and hereby authorize representatives afthls p -
1•- 2 city to enter upon the above-mentioned property for Impaction purposes. ALTER OR ADD TO MECH. Ian ,Date' Recei t#
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against 11 Il itles,;udgrrente,ro and anus which Tilly In anywayaceiue AIR HANDLING UNIT 10,000 CFM) - 'SUBTOTAL:
agalrw CI In mnsegit f e granting of Is Pe t
• AIR HANDENC uNrr(oviB Io,IOB crM) ' CONSTRUCTION TAX
a
Igna reef Applusta C ra or 95tcf D(HAUSTHODDIW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appliotit orfuture building occupant store or handle hazardous HFATINGUMT(TOIOO,O30BTLT) '
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Re,:d t#
I ealth and Safety Code Section 25532(a)P HEATING UNIT(OVER IREOW BTU) TOTAL•
F-1Y. No - - '
Will the applicant or future Wilding occupant use equiperent or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air contaminant,..defined by the Bay Area Air �srir�
Quality Management District? MOILER-GOMP(3HPOR10Q0(OBTlq -
Y's
No
9hmad , usmateriabrequlmmentsunder Chapter 6.95of BOILER-COMP(OVER 1W,000 BIM Q4
the California Health&Safety Code,Sections 25505,25533 and 25534,1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FTrutpoFj
priors Issuability nce
notofa Ceheoceupantof theupu requirements which most be met
prions Issuance o!iy the cuofOavparacy.
Owner or authorized agent ' Dae
TOTAL: ISSUED BY: OE-Z I Ays&.ai�atr/
OFFICE COPY