21536APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification -
Building Address: -2_
IC) Z tI Ci'
PERMITNO.
21 536
wrs ^ r.t ,s� - one:
N /l��sl �{t'{\' ' -
.CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION/ PERMIT
A
C Ira
:
'
BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL
CATPCORY
I
CONTROL B
`
Architect/Engineer. .- Lk. No:
`tELE.'I'RICI?ER[v(11`,
❑ ❑ ❑
Address:
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l sun licensed under provisions of Chapter 9(ormndo,
lican hSection 7000)of Dlvffect. o(the u neasandPro(essl aC-ode, and my
license late (o d(ect.
Llrek.p -
-
APPLIANCYSRESIDENTIAL
JOB DESCRIPTION
�1•/�
PANELS
Dat 'LM
Contractor
IQ 200 AMPS'
201-1000 AMPS
ARCHITECT'S re
I understand my plaru shall be used a public records,
'OVERIUNAMPS
SQ. Fr. FLOOR AREA
$/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professlanal' -.
SPECIAL CI(CUIT/MI5C
- OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law forthe
TEMP. METER OR E INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhich requires a perrtdt to contract, alter, Improve, demolish, orrepalr
any structure prior to its Issuance, ahomquirm the applicant for such permit to
file a signed statement that he is Iloenaed pursuant to the provisions of the
POWER DEVI
SWlMMIN L ELECTRIC Is
Contractors License law (Chapter 9 (commencing with Section 7000) of Divi-
sion3 ofthe Businessand Profenloru Code) orthat he in exempt theref emand
VALUATION
the basis for the alleged exemption. Any violation of Section 7011:5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
0 FI
five hundred dollars ($5W).
❑ I, as owner of the property, or my employees with wages as their sole
R D L L
[FR
570RIES
TYPE CONSTRUCTION
mmpennatlon,willdothe work andthe structure b not intended or offered for
01
couivir
site (Sec. 7044, Business and Professions Code: The Contractors License law
J
does not apply to an owner of property who Wilds or improve thaiaon, and
who does such work himself or through his own employees, provided thatwch
OCG GRCUP
RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building
improvementissold within omyearofcompletiontheowner-budderwili ha e
[t tturden o/proving that he did not build or improve for purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professiom Code:
TOTAL;
QT'y:' y`;�i!LIJMBING•PERMIT FEE,'i
,
FLOODZANE
APN
'
- PERMIT ISSUANCE
The Contructore License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contract s for such p(ojects with a
uanttotha Contraors LkemeLaw,
cgpt[actor(s)Ilcenaed purect
LJ I am exempt under Sec. B & P C for this' mason
- -
pLTQtDRAIN &VENTWATER (EA)
'.PEE'SUMMARY'
BACK FLOW PROTECT. DEVICE
OUTSI DE FEES
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES. ITER TRAP
SANITARY Y_ N_ -
RECEIPT p
Owner Data
11 TT WORKMAN COMPENSATION DECLARATION
1��1yy����TTTT((,,•DD•��hereby affirm that I have a certificate of consent to celf-baurs, or a
re/rlrypate o(Workers'Corppe BonImumnmoramnifica Mpythereof(Sec,
Zai
bC,) it1 �1 r 1!t PJ �,7 If1
Pollcyp V/i WC't- (-�r3
SCHOOL TAX Y N
RECEIPT #
GAS EA. SYSTEM-]INC.40 S
PARK Y_ N
RECEIPT#
GAS M-
EA. SYSTEOVERd )
Com pspy
- BUILDING DIV] SION FEES
Ivjlertlfled copy is ereby rnlshe
Certified copy Is filed with the city inspection division.
GREASE/INDUSIRLW TRINTERCEPTOR
PLANCI"IEGI�PEE
GREASETRAP
.' CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANT Y -STORM EA. 200FT.
COMPENSATION INSURANCE -
(rhlssection need not be completed lithe permit b far one hundred dollars
Date Recei t#
WATER W/VFM/ELFC'rR
ENERGY FEE Y N
($10D)mI..)
I certifythat re the performance ofthe work forwhkh this permit is lsmiad,
WA STEM/T'RIN7ING
I shall not employ any person In any manner so as to become subject to the
Workeri Compensation Laws of California. Date
PAID
Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
Date Remi t#
RESIDENTIAL PLMB. SQFF.
TOTAL:
should become subject to the Workers'Compsnsation provisions of the Labor
Cade, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
BUILDING FEE
SEISMIC FEE -
CONSTRUCTION LENDING AGENCY
Iherebyaffirmthat them isaconstruction lending agency for the perform=
anceofthework forwhichthispermitisb ed(Sec.W97,CIv.C.)
Leaders Name-
Leulars Addree
TOTAL:
ELECTRICFEE .
- ..
QTY::`• ,•' MEC"NICALPPBAMIT 'E"'
PLUMBING FEE
MECHANICAL FEE
I mAifythatl havereadthisapplratlonand state thattheaboveinformatlon
Is correct. l agree to comply with all dtyand county ordlnanres and state laws
PERMIT ISSUANCE Q
"ES PAID:
relating to building construction, and hereby authorize representative of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep baroness the City of Cupertino
ALTERORADDTOMECH.
Date Receipt#
SUBTOTAL:
againstliabpl��V���,,,�����pFFpaaaaaa rydgneents, costaand expenses which may in ywayacdur
against aai nconssryencoof a grantingofthlspermir^ /� /
_'/j/ V
rr
AIR HANDLING UNIT (TO 101000 CFM)
AIR HANDLING UNIT (OVER IO,WOCFM)
CONSTRUCTION TAX
<IN'^LI
Signatureo p lIcant/Contractor Dam
- EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
' HAZARDOUS MATERIALS DISCLOSURE-
Will the applicant orfuture building occupant store or he ad le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Date Repel t#
HEATING UNIT (TO 100," BTU) 00
HEATING UNIT (OVER IM OM RTU)
TOTAL•
Healthand Safety Cade Section 25532(a)?
Q Ye- NN.
VENTILATION FAN (SINGLE RESID)
_j�4aJs]CE DATE
Will the applicant or future building occupant use equipment or device
which emit hazardous air contarromnts as defined by the Bay Area Air
Qua lily Management District? -
Yes - ❑ No
read the hazardous materials regWremente under Chapter 6.95 of
i/ �s7s7a
BOILER -COMP OIT OR 100,CM BTU) -
BOILER -COMP (OVER 100,000 BTU)
the California Health&Safety Code, Sections 25505,25533 and 25534. I
SEP,,
L '
NEW RESIDENTIAL MECH. SQ.Fr.
understand that if the building does not currently have a tenant, that it is my
' responsibility to not ify the occupant of the requirements which most be and
prior to issuance of a Certificate of 0ccvpanry,
P a_, �f �it'nP�j^fl
0
1
DBY:
Owner or authorised agent Data
TOTAL:
OFFICE COPY