21379APPLICANT TO FILL IN INFOHMATION'VVITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address.• -
PERMITNO.
21379
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT
.BUILDING-ELECTRICA4PL[JMBINC-MFLHAMCAL
A L DATE
��y
� �(C).
re a
contractuni" ��}//�/�/�j o:
CATEGORY
CONTROL If
Architect/Engineer: - Llc. N
'$LECTAICPERMIT 1 ,`i�"PEE t
`'' BUILDING PERMIT INFO +
Address:
PERMITISSUANCE
❑ El ❑ • \� I
17Y_'I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provislonsof Chapter9(commene-
ingwith Section 7000) of Division 3 ofthe Business and Proles.lonsC.ode, and my
licenu Is In full force and affect.
License Cla — Lon
Date Contractor
ARCHITECTS DECLARATION
Iunderstandmyplansshagbeusedaspublicrecords
Licensed Protessloral
OWNER -BUILDER DECLARATION
[hereby offirm that am exempt fromthe Contractor's License Law for the
following reason. (Section 7031.5, euelness and Professlan. Code: Any city or
cwntywhlchrequimsaper ttoromtwcgaltegimpmve,demolbh,orrepair
anystructure prior to Its Issuance,alsorequirestheapplicantfor such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi-
sion3 ofthe Business and ProfessionsCode) orthat he is exempt there(romand
the basis for the alleged exemption. Any violation of Section 7031:5 any
applicant fora permit subjects the appllreat to a civil penalty M not nn than
five hundred dollars ($500).
❑I, as owner of the property,
p ork,a d my employees isswit tended as e1F le
compensation, will do the Business and k.andthe
ms Codurebeot Cmdura ca'. tfemdifor
sale (Sec. apply
to Busan iness Professions Code: The Contractors L1remedoes Llys
whorlnot applytorkhi ml orth=gproperty who nempds oy..,,P ssthereory antl,
who docs such work himself or tit rough Fie own employees, Prov Ided the t such
improvements are ria intended oroffered forsale. If, however, thebuildingw
i provementi ooldwithinoneyearofcompletlon,the ow ner-buBderwilln
t Barden o(pmving that he did not build orimprove (rn purpose of sale)
LJ L as owner of the property, am exclualveI contracting with Ilmneed
contractors to eomtruct the project (See. 7014 Business and Professions Code:
TW Contractor', License Law does not apply to an owner M property who
Wild. or Improves thereon, end who contra&. for such projects with a
Etractors) 0censed pursuant to the Contractor's License Law.
I am exempt under Sec. B k P C -for ehls'rcaeon
-
APPLIANCES -RESIDENTIAL
PANELS
JOB DESCRR'TION
rte"R\F/'
"
- 701-1000 AMPS
OVER1000AMPS
SQ.IFFLOORAREA
$/SQ. FI.
SIGNSELECTRICAL
SPECIALC_IRCUIT/MISCy�
- -
TEIAP.METl1Z ORPOLEINST.
-
; t �l (A
EWER DEVICE J `l
SWN1h(jNG TOOL;ELECCRic x 9
r VALUATION
-
d U.(yE1S5V✓[•fCFIGSFTX.I.URES
d'
r
NEW RESIDENTIAL` LECTR
sE �'pT•
SCORIES
TYPE CONSTRUCTION
+0
_
OCC.GROUP
RFS. UMTS
TOTAL:
Q'ry, :`",,. P['[jfy(BING PPRMI'F Yi •,,; pEE.C�,
PERMIT ISSUANCE
ALTER-DRAW kVENT-WATER (EA)
FIpOD TAKE
APN -
BACI( FLOW PROTECT. DEVICE
�' i ,, .''FEE SUMMARY
Owner Date
DRAINS FLOOR ROOF, AREA, CONE,
FIXTURES. PER TRAPSCIdOOL
SANITARY Y_ N
RECER'Tp
WORKMANCOMPENSATIONDECLARATION
❑I hereby affirm that I have a artlfivate of consent to self -Insure, or a
certifiwteofWork m'CompemationImumnmoracertifiedropythereof(Sea
3800, Lab C)�r �,-.r�j A�
Vollry p�/.v.Ci�•{r�.� /7
TAX Y . N _ -
RECEIPT#
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFEE Y N
RECEprp p
Com env-
�csrtBied
GAS EA. SYSTEM -OVER 4(EA)
BUILDING DIVISION FEES
ropy Is hereby rthe city -
CertRled copy le filed with the city Inspection divleion.
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(Thissect&
ion need nbe complMed if the permit Vre
(�rone hundd dollars
($1010)nrfess.)
hava.skmanner so as to bthis comermitia leveed,
[certify thatln the person
I shall not employ any person In any manner ro ss to become subject to theWorkers'
ApplicCompensation Lowe o(CallforNa. Date
Applicant
NOTICE TO APPLICANT: Il aker making this Certlflcate of Exemption, you
should become subj a to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such proal iom orthls permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a comtmction lending agency for the perform-
ante of the work for which this permit is owed &c. 3097, Civ. C.) -
Lander'.N.rrp -;;,
Lender'.Address -
I certilythat I have read this applicationand statethat theabove information
iii- ect.I ply with all city and crutyancews
nordin. and state la
relatingto dingro truth., aChatho�e representatives of this
citywerimruponthe ve-mentipection purposes.
agr to e, In mni(y the City of Cupertino
Hes dg may In anywayaccrue
againstsal C Inca en Somali.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE'
PAID
Date Recti t#
GREASE TRAP
SEWER-SAMTARY-STORM FA. 200FL
WATER HEATER W/VENT/ELTATR
ENERGY FEE Y -N '
-
PAID '
Date Recei t#
WATER SYSTEM/TREATWG
NEY✓RFSIDENT/AL PLMB. SQ,FI,
TOTAL:
UILD NG
-
-
TOTAL:
SEISMIC FEE
ELECTRIC FEE
y...
QTY, i;;i'. hfECHANICAL�P6RMIT FEES"
PLUMBING FEE "
-MECHANICAL
1
PERMIT ISSUANCE a
�,&3
FEE,.'
FEES PAI U. -
ALTERORADDTOMECH.(We)
AIRHA,NDLINGUMT(IO10,000CpfvDSUBTOTAL•
Date Receipt#against[lab
AIR HANDLING UNIT(OVER 10,000CEM)
CONSTRUCTION TAX
'
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.fined future occupant More hhand91Zanrdous
Municipal Code, Chapter 9.12, and the
material as defined ode Section
Health alt Yard Safety Code, SeNioon 75537(a)7
Will the applicant or future building occupant use equipment or devices
,which emit hazanl... air contaminants as defined by the Bay Area Air
Management District?
FI Yea g No
have read the hazard u. materials regWrements under Chapter 6.95 of
the California Health & Salary Code, Sections 25505, 75533 and 25534. I
and ersta ad that if the buildingdoes not currently have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
priorlotmuanceota Cedificateof0cwpancy,
EXFIAU5THOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU) .�
Date Recel t#
HEATING UNIT (OVER 100,000 RTU)
TOTAL:
�6V
VENTILATION PAN (SINGLE REBID)
ISSUANCE DATE
PAID
ry { ����
(„J
/�:} a� a.
'A" Ad
ISSUED BY: � �'� '
BOILER -COMP OHP OR 100," BT N
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL�.1 MECH. 5(j.FT. '
Owner or authorized agent Dale
' TOTAL: u C7/
OFFICE COPY