21520 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PFIMTNO.
Building Address. 21520
wnere a l F� �e: - _
CITY OF CUPERTINO-BUILDING DIVISION Yl ontractor's me: Lie.No: APPLICATION /PERMIT b^i
N` V BUILDINGO.ECTRICAI.PLUMBINGMECHANICAL CATEGORY CONTROL N
Architect/En r. Lk.No:
BUILDING PERMIT INFO
QTY .ELECTRICPERMIT FEE
Addrese: �Wtoll a(rI —aa, PERMITISSUANCE
- LICENSED CONTRACTOR'S DECLARATION
!hereby affirm that l am lkensed under provislons of Chapter9(mmmmc APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwith Section7000).!DiWk..3ofthe Busiruaand Pm(mQ ns Codgandm
license Is In full force and effect.3 O PANELS - 2 �
Lkense Class Lie
Date Contract I -
ARCHITECPSDECIA TION C 201-1000AMPS
N7, ]understand myplamshallbeused aspubllcremrda OVERI000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
q� O
Fi Licensed Professional SIGNSELECTRICAL
OWNER-BNLDBR DECLARATION SPECiALCIRCUIT/MLSC �\ �• E ® '
L., a 1hembya(firm that l am exempt from the Contractor's License law for the '
Ooo lollowingreason.(Section7 tmBusinessand Profession,Code: h, ci r rs ,1 r�
z Y ty° TEMP.MET[R Oft POLE INS!. '\VAC/ IB',.,J
0 munlywhirh rcqulresa permit,comtmuiresthe apmvgderrolbh,.rto
g anystructure pristatement
erto ments hat he is also sed purtheapp the provisions
ofpermit e
L5 thea signed statement that he b licensed pursuant to the Pon 7000) of Me POWER DEVICES {
0060w1. ConlollhaLicense Law(Chapter"Cme)o,cingwith Setlion7000).(Diel. - DA
�30J elon3.fthe Business and Proteml.,Code).rthat he is exempt lhere(romand SWIMMING POOL ELECTRIC.
Eb .••7777 the baso for the allegedexemption. Any violation of SeNon 7031.5 by any - a/_� yr
applicant Ems permit subjetm
ethe applicant to a civil penalty d not ore than VILETT.SWITCHESFIXTURES GLJ
live hundred dollars($500. NEW RESIDENTIAL ELECTR• Fr,
❑I,as owner.f the property,or my employees with wages as their sole �' STORIES TYPE CONSTRUCTION
compensation,will do the work and the rtreture Is not Intended or offered for
sale(Sec.7040 Business and Professions Code:The Contractors License Law
3$ does not apply to an owner of property who builds or improves lhereory and OCC.GROUI' RES.UNITS
who does suchworkhimnitorthrough hisownemployees,provided that such
Improw.r.msare not Intended oroffered Aussie.11,howevegthebuildingor TOTAL; 4. a
le
Improvement issold within.m)earof completion,the owner-bu0derwBl have
tIg.rdeoofpmvinglhat he did nmbuRdmimpmemforpurposeofsale.). QTy, . PLUMBING PERMIT FEEPLO ,zONrg ApN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or improves thereon, and who contracts for such pwjets with a
cgn(IaemKs)licensed pursuant to the Contraten.License Law. ' FEE SUMMARY
LI I am ezempl under Sec. B k P C for this reawn BACKFLOW PROTECT.DEVICE 011TVIV FEE,
•
Owner DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N Date RECEIPT
EC--
WO affirm
th=I OMPENSATION DECLARATION F)%TUREZ PER TRAP SCHOOL TA Y— N—
❑I hereby aftlrm that I have i Insu.re of consent to upytnsure,ora RECEIPT N
3800,LabCtertificate..Workeri Comperuatlon lruurenre ora renitkd ropythere.((Sn. GAS-EA.SYSTEM-1 INCAOUTLE1'S PARK PEE Y N
350D,Lab C.)
Compolkcy n GAS-EA.SYSTEM-OVER 4(ERING DI p
0Y A) BUILDING DVISION PEES
Cerlined copy is hereby furnished.
thcity
ty
❑Certified copy with
the city inspection division. CREASE/INDUSTRL R
WASTE VTERCEPTOR PLANCHECK FEE
'
CERTIFICATE OF EXEMPT[ON FROM WORKEKS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20.171'. Date Reo6i t#
(This section need not becompleted!(the permit b!.Tone hundred dollars
(ETI tartly that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
tartly,ploy ary person
in an !manner fo as to b co pennlHa lasued, —
I shag not employ any person In any mannerso ss to become subject to 1M WATER SYSTEM/TREATING
Workers'C.mpenution Laws of California.Date PAID
C) Z Applicant NEWRFBIDENTTALPLMB. SQ.FT. Date Recel t#
Z O NOIICETO APPLICANT.If,after nuking this Certificate of n,You
should become subject to the Workers'Compensation pr.vlaloru of the Labor TOTAL:
N Code,you at forthwith comply with such provisimu or this permit shall be BUIL
deed revoked.
LU
0 meCONSTRUCFION LENDING AGENCY, SEISMIC FEE
I hereby affl that there Is a construction lendingagenry for the perform TOTAL:
ELECTRIC FEE �O
Q O anceof the workforwhkh flab permit Is Issued(See 3097,Civ.C.)
LL _ Lender's Name PLUMBING FEE
LL L) Lender's Addreea QTY. ' MECHnformationANICAL PERMIT - FEE MECHANICAL FEE
O W Iced.Id rectohave read twithalimtl°nandunty hat ordinances a dmate laws
f1 Iscrelatingtoagrm/o complywo,andhereb countyordinances
repneesand mate awe PERM777SSUANCE FEES PAID:
} N city ingnbunter ilding the above-mentioned
hereby authorize reprenn urpos.(this
[— airy to me)
the above-mentioned propeharml inspection purposes. ALTER OR ADDED MECH. Date Reeel t#
Mie)agree toss Indemnify an d keep harmless the City of Cupertino P
against llablWies,' m,costsand expenen which may In any wayacerue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL;
aga Wt said City nmquen oft grantin fthlspermt -
�..Js�/� 1�_ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant Contractor D- ale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hazardoua HEATING UNIT(TO 100,000 BTU) Date - ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
IiealthandSafety CWe Section25532(a)7 HEATING UNIT(OVER 100,00D BTU)
F-1 Yea r�i No TOTAL: '1'%-1 10
Will the applicant orfutere building occupant use equipment or devices VFNDLATION PAN(SINGLE BESIDE DATE
which emit hazard..,air contaminants a,defined by the Bay Area Air
Quality Management District? BOILER-COMPOFIPOR 100,000 BTU)
Yen No a�
4havemadtheh &Safer Code,
BOILER-COMP(OVFR100,000 BTU) nca v
the CalBomlalieahh ASalety Code,Setlioru 7550.5,25537 and 25536.1 T96H -i
understand that if the Wilding does not currently have.tenant,that It he my NEW RESIDENTIAL MECH. SQ.Fr. ,
respomoccupant
ibllltyto notify the occupant of the requirements which must he Tref Asa -
ftprior toissuan a Certifiraleot Occupancy. - iAb7L{�$ Nom,
lhvnr athonmdagent Date - TOTAL: ISSUED BY: �aUr%Rt W'H0�'"C
OFFICE COPY