21309 APPLICANT TO'FILL IN INFORMATIONVITHIN RED LINES — USE BALL POINT PEN ONLY
.Building Project Identification I - PERbBT NO. '
,. Building Address:
ner a . • L pct-[ V 21309 On
ame: A
CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lic.No APPLICATION / PERMIT
�U—Z�C
BUILDING ELF MCAL-PLUMBINGMECHANICAL CATEGORY CONTROL p
Architect/Englnrer. - Lk.No - r
e '•tY tSt t "j ' ) 1' s ' ) ° ¢' "BUILDING PZiAMITtINFO-. ;,.
E[.ECTRiCFERMIT
.i Address:. - ..
PERMITIS5UANCE _ ❑ ❑ El CONTRACTOR'S DECLARATION
I hereby affirm that l are licensed under provisions of Chapwr9(commme. "PLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Sed1onMW)of DwIuon3 ofthe Businessand PenfeagereCode,and my
'license is In fyjor yd died. 5 PANELS
License Claes------
-- Lic.p 7- q
'
Date /z9--±a-Af)Ccourador ..-�- /�! -
ARCHITECT'gDECLARATION (�y- 201-1000AMP5 a
9z +I understand my plans shall be used w,public records. .OVER 1"AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Rob
Licensed Professional •b,x, r SIGNSELECTRICA -
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M }
i., Ihereby afRrmtliatI am exempt from the Contractor's License Law for the
'Zo following reason.(Seeder,7031.5;Business and Professions Code:Any city or uTEMP.METEROR
oentywhich requires a permit tocoretruc5 alter,improve,demelbh;orrepalr POLE ST
Q 8 anyatrudurepriarwttelastance,.]sorequlreatheappllantforsuchpermltto POWER DEVICES
F file a signed statement that he is licensed pursuant to the provisions of the 4. -
FWj3", Contrador's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIWMNG POOL ELECTROVALUATION
F�O� elon3ofthelktamonsand Professbm Code)orthat he
exemptlherefromand
0 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLET SWIMIrl
apphantforaper tmbjedstheapplkanttoacoilpevltyof,n&mmtl n 3 Doc) 06
fivehundred dollars($500).I . NEW RESIDENTIAL ELEC 'SQsr, STORIES . TYPE CONSTRUCTION
j F1 as owner of the property,or my employees with wages as their sole
compenaadon,will Bothe work endthe strodure Snot intended or offered for
psale(Sec.7044,Business and Profeadmis Code:The Contractors License law
$ does not apply to an owner of property who builds or improves thereon,and
whodce suchworkhimselfoithroughhisownemployees,providedthatsuch _ 'OCC.GROUP RES:UNITS -
improvements am not Intended oroffered forsele.It however,thebuilding or TOTAL:
improvement asold withinoneyearofcompletickthe Owner-bulMerwlll have .:.«x,set„, i it en of proving that he did not build or improve for purpose of sale.). (QTY;„x";,{",PI:�111'IBIN(i; ERMIT:}��•«,'''i.:f:1FEEti': M' FLOOD ZONE APN
Lf 7,as owner of the property,em exclusively mntrading with licensed PERMIT ISSUANCE
contradicts to construct the pm*d(Sec.7644,Business and Professions Code:
The Contmdor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATQ4(Eq) -
builds or improves thereon, and who contracts for such pkojeets with a �l'ri '� y'+FEE',$UMMARY,7 t a •+"
cgB(fador(a)licensed pursuant to the Comndors License Law.
E I am exempt under Sec B &P C.for this reason BACK FLOW PROTECT,DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date BBC=p ,
WORKMAN COMPENSATION DECLARATION - MTURE�PER.I.�I, - SCIi00L TAX Y N
•� ❑I hereby affirm that I have a certificate of consent to self Incur r a RECEB'T M
muchIcateofWorkers'Comper timlruurmmoracertiftedmpythereof(Sec. GASEA:SYSTEM.17NC.40UTLECS d' PARK FEE Y N
3800,Lab C.) - —
RECERx1'N
'( PolicyN GAS EA.SYSTEM-OVER Com any BUILDING DIVISION FEES
�Ccrt fied copy is hereby furedshed. - GREASE/INDUSTRL WASTE INTERCEPTOR' PLANCHECK FEE "
F-ICedified copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP , PAID '
COMPENSATION INSURANCE SEWEk-SANITARY-SCORN EA 2WFT Date Recei t#
(Thlsaectlon need not be completed if the permit te forces hundred dollars
4100)orlexa.) - WATER HEATER W/VENT/ELECT'R ENERGY FEE Y N
I retlfy rthat in the performance of the work for which this permit la Issued, —
I shall not employ any person In any manner so,as to become subjed to the WATER SYSTEM/TREATING
Workers'CompensaOun Laws of California.Date - PAID -
OZ Applicant - NEW RESfDENTIAL PLMB. SQFf., Date - Recei t#
Z O NOTICETOAPPLICANT:If,aBermakingthls Cediflcateof Exemption,you .-"
should become eubjed[o the Workeri Compensation provisions otthe Labor - „y. TOTAL: - �O
a'C
I— Code,you must forthwith comply with such provisions orthis permit shall be
CC, deemed revoked. - BUILD! EE t
CONSTRUCHONLENDINGAGENCYe'' SEISMIC FEE
Ihereby affirm that there 6 a constrodlon lending agency for the perform, t TOTAL:
MELECTRIC FEE
� Z ance ofthe workforwhlch this permit is iiaucd(Sec.3097,Civ.C). O• Iandere Name .. -:, . „ - • �. PLUMBING PEE
F' Lender's Address QTY, MECIiAN_ ICAL�PERl1`1CF tl„):SLI
LL O Icertlfythat I have read this application and state thatthe above Information t t MECHANICAL FEE
O W' awrood.l agree to comply with a0 city and county ordinances and state In. PERMIT ISSUANCE FEES PAID:
1• U) relatingmbupongmndiurnxmared proprtyor for Inspetionpurpssofthis -
'F'N cityto
to theabovensubpnedpropehTymless the Cit purposes. ALTERORADD TO MECH. -
Z " Date ' ' Recei t#' . -
-.
(We)agree to sevglndemnl ep.har bl'ti a inany Cupertino AIR HANDLING UNIT CFO 10,000 CFM) ' P
against llabllities,rydgme dex n awhlch may In anywayaccrue SUBTOTAL:''- '
a 'n dy Inc ne an o this permit.
x AIRHANDLINGUNIT(OVERI0,000CFM) ` CONSTRUCTION TAX -
sig of pplidmt/Contrador ,Date " EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: .
' HAZARDOUS MA RALS DISCLOSURE '
Will the applicant orfuture building occupant store or handle hazardous' - HEATING UNIT(TO 1W,W0 BTU) Date Reozii t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the 1 1
Iiealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) 'TOTAL: "ls be
Yes No
Will the applicant or future building occupant use equipment or devices VENDLATION PAN(SINGLE AES[D) ISSUANCE DATE -
whichcenthazardousaircontaminantsasdefinedbytheBayAreaAir "- t Z%A ryas
Ogald�Management DistdNo, BOfLER-COMP(3FR'OR 100,000 BTID ,4�'p1R4A
44havereadthebaza2usmaterials requimmentsvnderChipter693of BOILER-COMP(OVER 100,000 BTU) 7 { Q
f. the California Health&Safety Code,Sections 25505,25533 and 25534.I •` OCTC ON
understand that tithe building does not currently have atenant,that it is my NEW RESIDEN7TAL MECH.- SFT. t
resporeibildyto'noti(ytheoccupant ofthe requirements which must be met �,$
prior to issuance ofa Certificate of Odupanry. _ C of.CupowCK 31
Owner or authorized agent Date - ISSUE BY: !^t��W
OFFICE COPY