21343 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
tiullding Address: , 21343
y�o sx Lower
nets / one: -
=�QL); zrw6h4iQ r �$-7—llljlrP� CITY OF CUPERTINO-BUILDING DIVISION
�. cnmr Gc.No: APPLICATION,IPERMIT
Q ✓e(p ` CATEGORY CONTROLp
BUILDING-ELECTRICAL.PLUMBING-MECHANICAL
Arc tea/Engineer. Lie.No:
Ql'Y'. ,ELECTRIC P'E�RhtIT )�?]:Ep; BUILDINGPERMIT.INFO '
Address,
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby affirm charism RceneeduMer provolone of Chap[er9(rommenc APPLIANCES-RESIDENTIAL .,JOB DFSCRIIxTTON
Ingwith5essi vlelon3oflheguslneesendProfeaelonsC-ode,and my �� �/J `
liPANELS
LceCI
Date Contraaor Yy�/{"�/f P.✓`7IGeLJy�r//yu�'`//�N"1�
ARCHITE A DE ATION OVER00 AMPS
x 00❑'Z I understand my plans shall be used as public records. OVER 1000AMPS SQ.Ft.FLOOR AREA $/SQ.FL.
gwl
Licensed Professional 1,SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION �} y '
Gi Fd P// .�.i'' SPECIAL CIRCUIT/MLSC
L., I herebyafflrmthatl amexempt from the Contractor's License Lawforthe
Z po ❑A following reason.(Section 7031.5,Business and Pmfesabne`Code:'Any'iity or -
Fz^ counlywhichrequlreeapmmltro owtross,alteq improve,"demnlieh,mrepalr TEMP.MhTFROR POLE INST.
any s[maure prlortoltibwance, Iso requlrcatheappllcant(orauclepcmutto
rxE V file a signed statement that he i Icepsed'purauant to the provisions of the n POWER DEVICES
O k M Contrach is Licems,Law(Chap[r9(mmirsncing with Section 7000)of Divi- /,% I1
�iof+a SWIMMING POOL ELECTRIC
�0� the basis for the
alleged
d Profemlon. Any orlation f exemptthere5 'I'" - -' - VALUATION
the basis for the a11egM exemption. Any violation of Seaton 7W1!5'�pyitiny`
G
applicant fora permit subjects thea licant to a civil real of nut more Phan �� Oil7i'ET'SWITC}{FSHX7'URES
fve P K PP P /'' k
o flue hundreddollarsof hepr. / It/ 1( NEW RESIDENTIAL ELLCTR SQ,FT, STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the properly,or my employees with wages as their sole
Ocompensation,RaMna.he work and 16.C6dum b not intended or offered for
In(Ser.apply
to se
df pmpelo'ne Cobuilds Compactor's Llrerse Law
�.2 does not epplyto an owner o(propeity`,nlio builds or improves thhe�reon,and, OCC.GROUP RES.UNITS
whodoessuchworkhlmaelf orthrough hl'eeownemployeee,provid%thatluchr
ireproverecntsare not Imendedorof(eredfm IQ howevegthe sliding or TOTAL:
improvementbaoM set inoneyearofcompidi gtlu. svlrer-build rwlll.ave
t1�n ben of proving thalMdid na baud ori p ve lm purpoa ofsale) QTY: 'i'.� 41:UMBINGP RlvI1T " FEE.''`•' FLOOD ZONE -APN
LI 4 ae owner of the property,a((nn er}duel ly Eontrilting wi h Ilre sed PERMIT ISSUANCE
mntraaore to. pro)ed(51c. B sinew and Prole fors Code ,
The Contractor's Lacunae law cora opt apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) '
builds or Improves thereon,and who rontraob for such projects with a
on .p .r(s)hcenwdpureuanttottie Contradw's Liwnw Law. BACK FLOW PROT[CT.DEVICE r `t't ' :FEE;$OMMARY�
lam
exempt under Sea.- B k P C for,this reason
OUTSIDEFVES
Owner-� Date DRAINS FLOOR,ROOF,AREA,COND. SAMTARY Y_ N
WORIONAN RECEIPT M COMPENSATION DECLARATION pD(TURES PER TRAP SCHOOLTAX Y_ N_
reby affirormlom that I have a Insurance
of consent to eeif-Ineurc,ora RECEIPT p
IflcateofWorkerc'CompewaHwlrsuranre marerti(kd ropythereof(Sec. GAS,EA SYSTEM-I INCA OUTLETS
3800,1ab C.) �p �1g PARK FEE Y_ N—
Poliq•it GAS-EA.SYSTEM-OVER (EA) RECEIPT a
Com any 6D - BUILDDINGINGDIVISION VISION FEES
[]p eAllied copy is filed w th the city GREASE/INDUSTRL WASTE IN'T'ERCEPTOR PLANCHGCK FEE
cai(ied copy b filed with the city inspection division. _ -
CERTIHCATEOFEXMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(!MSEWER-SANITARY STORM EA ROOFT Date .Rett'1 t#
e section need nbe completed if the permit b forone hundred dollars
(81I mthly that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill not that in the performanceperson
iany m neerwork se Main
betonh this permit b booed, -
I shall not employ any percon in any manner m ae to become subject to the, WATER SYSTEM/TREATING
Workers'Compensation Iowa of California.Date PAID
O"Z Applicant NEW RESIDENTIAL PIMB. SOFT. Date ReCel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you -
should become Subject tothe Workers'Compensation provisions of the Labor - TOTAL:
N Code,you mu at forthwith comply with such provisions orthb permit shall be
j deemed revoked. BUILDING FEE Moo
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE '
I hercbyaff(rmthat there is a construction lendlegagency forthe perform ELECTRIC FEE
D Z once of the work for which this permit is issued&c.3097,Civ. TOTAL:
O O Landers Name - PLUMBING FEE
U. F Lrnder'sAddmas - QTY:'."' ,1MECHANICAL'PEFtMIT MECHANICAL FEE
O W Imrtlfythat]have read thbapplicationand statethatthealmveteformation -
a bcorrea.Iagree to comply with all city and munlyordinances and state laws PERMITISSUANCE FEESPAID:
- y relating to building construction,and hereby authorize representatives of this
H-Z. city toenter upon the above-mentioned'preperly for inspection purposes, 'ALTER OR ADD TO MECH. Date Memo#
— (W ogee to save,Indemmfy an d kre armless the City of Cupertino P
aga t abimlea,jadgments,costs sex s hick may In anywayamrue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL,
ag old yin ran ue o fie g of thts permit. `
- 5'D AIR HANDLING UNIT(OVER lo,000 GEM) CONSTRUCTION TAX
SI tureof Applicant/Contractor f Data IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU) Date ;R0Ce1 f#
material as defined by eCupertino Municipal Code,Chapter 9.1$and the -
IiealthandSafetyCode on25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: '
0 Yee No
Will the applies to future building occupant use equipment or devices VENTILATIONFAN(SINGLE RES ID) ISSUANCE DATE
which emit hazardous Ire ounanteae de dby the Bay Area Air
Iia lity Management A, BOILER-COMP(3HPO R 100,000 BTU) PA'® -
Yce o f1
-•: have read t'cha case materials requirements undeiChapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
tfie California Heal &Safety Code,Sections O5,25533 and 25534. I
understand that if the building does net torr have a tenant,that itis my NEW RESIDENTIAL MECH. SQ.17. .x7711[[
P. 'litytonodytheocce a ofthe meets which mu at be ma '
prio uan of a Ce h o ccup y�
Ow rotauthorludagent - Ua[e ISSUEDBI� K 4 k
TOTAL:
OFFICE COPY