21403 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES= USE BALL POINT PEN ONLY
Building Ponied Identification - PERMIT NO.
Building�Add ress 21403
D/
00-
wn�a are:
rSjVKk 7;5
CITY OF CUPERTINO-BUILDING DIVISION A
4 cera ado eNa uc. er. APPLICATION / PERMIT
C r U BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL p
Arc ited/Engineer. LIc.No
- .QTY• t ELEQTRICR RMIT ..... BUILDINGTERMIT'INFO
dreea: A d . PERMITISSUANCE '+'• % �. � 1:1m
LICENSEDCONTRACTO DECLARATION
]hereby"mr.rhat l am licensed under provisions of Chapter9(commnc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION dion7000)of Dlviaion3ofthe Businemand PmfesslonsCode,and my
license Is In full force d effect. PANELS n
License = Cn Cco p
Date Contractor A �N�C'a• . 701-IMO AMPSp (r
UP TO 200AMPS�
ARCHITECTSda LARATION
XX -Iundentand my glare shall be used as pubecrerords OVER 1000 5Q.F.FLOOR AREA $/SQ.FI.
p��++ ON ELECTRICAL
Licensed Professional SIG
<<�< OWNER-BUILDER DECLARATION 5I'ECIA C[S4T/MIST
0 I hembyaffirentbatl am exempt fromthe Contractors License Lsw for ��^
Z O
following reason.(Section 7031.5,Business and Professions Code:An cityo e�
O Z a S Y l TEMP.. . ORPOL IN
countywhichrequbesaperMttomnstmd,aller,impmve,demolleh,mmp
.ai anystmd mprlortolts6wancgalsomqulmatheappllrentforsuchpermit DEVIC
r a file a signed statement that he Is Brensed pursuant to the provisions of t e ``
3 m Contractor's License Law(Chapter 9(commencing with Seaton 7000)off) SWLMMING[POOL ECTRIC
sion3ofthe Bustnenand Profemi.uCWe)orthathelsexempttherefmmddddddnd - VALUATION
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITC[iESFl%TURFS s
applicant for a permit subjects the applicant to a civil penalty of normore tha , C
five hundred dollare($500). NEW RESIDENTIAL ELECTR ar' SQ.Fr. STORIES TYPE CONSTRUCTION
�e ❑I,sa owner of the property,or my employees with wages r their sole
compensation,will dothe work and ionstmdereh Contenders or offered for
selq doe(Sec.apply
to aniowcis and f property
Code:The Contractor's Limnu law
docs not apply loan owner of property who bunds or Improve thereory and
e,
who does such work himself orthreugh his own employees,provided that such OCC.GROUP RES.UNITS
improvements are not Intended or offered for axle,If,however,the building or TOTAL:
improvement issold within one yearofcompleim,the owner-builderwill have
thrt*rdenof proving that he did not build or Improve for purpose of axle) (ZTy�" IsL BING PERMIB` •CFEE:'.•- _
u L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
PERMIT ISSUANCE .
contractors m rorotrud the project(Sec.7044,Business and Professions Code; QO
The Contractor's Limes Law dcea one apply to an owner of property who - ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojece with a ..FEE"SUMMARY
c,Iltjador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.LII am exempt under Sec. B &P C for this mason
OUTSIDE FFFq
DRAINS FLOOR ROOF,AREA,COND. SANITARY .Y N
Owner - Date - RECEIPT R
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP 5C7{OOL TAX Y_ N
4� �I hereby affirm that I have a certificate of consent to self-insure,ora W RECEIPT p
c 10camo[Worken'Comperuatlonrrisurance ora certified ropy thereof(Sec. GAS EA SYSTEM-1 INCA 3S00,Lab C.) PARKFEE Y_ N)ol
Coir an CAS EA,SYSTEM-OVER is RECEIPT#
P y BUILDING DIV]SION FE ES
Cert[ ed copy is hereby filed
th ed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city inspection divlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tic
(This section need not bmes hundred dollar
e completed if the permit is fo
($100)orless3 - WATER HEATER W/VENT/E^ECTR ENERGYFEE Y N
[certify that o the performance of nythe
nuwork fors to b this permit Is Issued, —
I shall not employ any person In any manner so as to become®rbject to the WATER SYSTEM/TREATING
Worksre'Compensatlon Laws of California Oats' � PAID
O Z NOTIAppliCE
NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei tit
Z O OTLCE TO APPLICANT-.If,akar making this Certificate of Exemption,you
should become subject to the WorkerCompensation provisions of the LaborCC
TOTAL:
n, Code,you most forthwith comply with such provisions or this permit shall be BUILDING •E
deemed revoked.
IL —p - CONSTRUCTION LENDING AGENCY - SEISMIC FEE
te
Iberebyafflrm that there is a construction lending agency for the perform- ? ELECTRIC FEE
Z anof the workfor which this permit is Issued(Sec.3097,Civ,C.) TOTAL Jct .
V O Lenders Name - PLUMBING FEE
3d,o[y
U. Lenders Address QTY MESHANICAG PERMIT FEE-'( MECHANICAL FEE
O W Icertily that[have read this application and date that the above Information
Is carred.[agreeto comply with all city and county ordinances and Rate laws PERMITISSUANCE FEES PAID:
T 0' relating to building construction,and hereby authorize representatives of this
?N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECLL
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date-." Reeeipttl
V against liabilities,judgments,rortaand expenses which may In anyway seems AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: LYJ
againittodd City ns ofthegantingofthla cermlt. "
erre p /!_^ _� AIR HANDLING UNIT(OVER 10,000 CID CONSTRUCTION TAX
Signature of Applicant/Contractor - Dale ExHAUsr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
•Will the applicant orfuture building occupant store or handle hazardous HEATINGUNIT(TO100,0001IN) Dale RCCeI of
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTW TOTAL: Cid
Yes , ,L{�nL No
Wllltheapplicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) -.ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air _ PAID Quality Management District?, BOMER-COMP MI'OR 100,000 BTW
4 have oz
Yea 0 No
mad the bo oma materials requirements uder Chapter6.95oBOILER-COMP(OVER 100,00 BTU)
the California Health&Safety Code,Sections 75505,233 and 75534.I - NO 9 V 19J0
understand that if the building does not cartently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Fr.
responsibility to notify the occupant of the regmbements which must be met ���sa VI,
prior to issuance of V rd of0cc,ipancy. V1.Coolie.
Owner or antroiEndagent - Date ISSUEDBY:
TOTAL:
OFFICE COPY