21581 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
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idng Addrao- 21581
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/5jrtlll/w c..-/Gga"97—' 7 CITY OF CUPERTINO-BUILDING DIVISION
N' :` Lic.N. APPLICATION / PERMIT �` 9�
[-T/ BLULDINGELECTRICALPLUMBING- CATEGORY CONTROLX
Architect/Engineer. LIc.No: MEC}IAMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmmc APPLIANCESRESIDENTIAL JOB DESCRPDON
tngwhhSection7000)ot DiWnon3afthe Bunnemasd ProfesnonaCode,and my limms
Limnrea�Is in tu}Storcr�nd keep. PANELS
Date m(/�1L.4,i FiT'/ Contractor //A,Qct -1
ARCHITECI`B DECIARATI •'J / 7t11-IOW AMPS
90 I understand my plans sbaB be used as public remnls. OVER 1000 AMPS .FLOOR AREA f/SQ.FT.
oLicerscd Professional SIGNSELECTRICAL
6 ° OWNER-BUILDER DECLARATION $I'FCIALCIRCUfT/M �I -j 111 d ' N
1., � ]hereby affirm that lamexempt fromthe Contractor's Liceoae Lawforthe
Wfollowing reawn.(Sd.Has 70315,Business and Prof inions Code:Any cityor
'8 muntywhkhrNulresapemtt mmt adAter,Improve,demolhh,orrepalr TEMP.METEtOR!'OL
NEI any structure prlorto lb lmuance,alsorequires the applicant(arauch permit to
ES U file a signed statement that he Is licensed pursuant to the provisions of the TOWER DEVICES
g 3 ra Contractor.Lkersc Law(Chapter 9(commencing with Section 7000)of Divi- DATE
SWENAI]NG 700E ELECTRIC
non3 ofthe Buslnmrand Pmfembm Code)orthathelsexemptthemfmmand - VALUATION
'g the balls for the alleged exemption. Any vlolatlon of Section 70315 by any
applicant u m
for a permit subjectathe applicant to a civil penalty of not than OUTLETSSWITCIiESHXT[lRES
five hundred dollars($500). NEW RESIDENTIAL ELECTR FT.
L an owner of the property, SQ. STORIES TYPE CONSTRUCTION
7< p perry,or my employees is with wages r ]Mir door
compensation,70K
usiness workandthes Code:
reh not Intendedo License Law
D sale(Sec 7014,Business and f property
rops ty Code:The Contractors vest harem law
s(� whodoesuchdoes not a pply torn imserofproogh hisorompbuilds arimproovided thatand OCC.GROUP RES.UNITS
whoovementsworktinteded orwgh Maowne.If,ho eprovidedthatsu or
improvementsarcnm Intended earofc !oleate.IL inner-q deer ilI have TOTAL:
improvementlsmld wlthlnoneycaro(compldloMthe owner-bullderwill have
t1A_)lurden of proving that he did not build or knprow forpurposeafsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Lf 1,as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
to mvtrud the project(Sec.70ty Bualnem and Profemio sCode:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilda or Improve thereon,and who contracts for such psojeu -
a with a FEE SUMMARY
cgB[ladm(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B k P C for this reason
Owner pate DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT N
-- //WOR WAN COMPENSATION DECLARATION ppC7VRF5,PER TRAP SCHOOL TAX Y N
mn__by af(Iret that I have a certificate of consent to eeWinsure,or RECEIPT X
moo,1.whiflateofWorken'CompewaRonlmuranceora certified ropythemof(Sec, GAS F.A.SYSTEM-1 INC4 OUTLET
policy Lb C.) PARK FEE Y_ N
Po11ryY GAS EA.SYSfEhf-0VER4fEA) RECER'fX
CErn7—G�rh��i>• TPi BUILDING DIVISION FEES
LJCficifind copy ls herebyNotated.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�{.rrtified copy ls filed with the city Inspection division.
CERTIFICATE OF]EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.2(IBrT. Date Recd t#
R)or loran need cad be completed If the permit ls forone hundred dollars
(810 mmless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
]comfy that to the person of
manner
so whichas too co permitis Issued,
I shall not employ any person In any manner n as to become subject to the WATER SYS EM/TREATING
worlicn Compenution laws oeGia
llfom .Date PAID
O Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
ZO NOTICE be..
OAPPLICt to the
frkers'er ingthlsCtion pre of ofteLyou
H
Cdc,you
at forthwith
co Workers Comperoviins orchis permit s Labor TOTAL:
W N dremcdre mixed. hwllh comply with such provisions orlhls permit shall be BUILDING
� deemed revoked.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirm that there 0 a construction lending agency for the perform, TOTAL: ELECTRIC FEE
V7 O anceo(theworkforwhkhthlspermitls Wuet(Sec.3097,CIv.C.) PLUMBING FEE
Lender.Nams
IL H Lender'.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mnllythat l haveread thlsapplicatlonand nate that theabove lnfomutlon
1 iscorrect.l agree to complywith all cityand county ordinances and nate laws PERMTr ISSUANCE FEES PAID.
>. W relating to building construction,and hereby authorize representatives ofthls
F` Z
MNFW
bove-crimloned property for Wpection purposes. ALTER Oft ADD R7 MFCH. Date Reeei t#
Indemnify an d keep barmlm the City of Cupertino Penb sandexpen Ichmayinanywayaccrue AIR HANDLING UNIT(r0 IQ000CFM) SUBTOTAL•
re it an Tibia perms. a_AAAIR HANDLING UNIT(OVER IQ000CFh1) CONSTRUCTION TAX
Slgromm of Applicant/Cdotractor IDate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appficant or(uture building occupant store or he nd le hazardous HEATING UNIT(TO 100,000 BM
material as defined by the Cupertino Municipal Code,Chapter 9.12•and the Date RCCeI t#
Heals h and Safety Cade Sectic%� 32(a)1 HEATING UNIT(OVER ifle"8TU) TOTAL• Q r
M Yes H6
Will the applicant or future building occupant use equipment or devims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazar=.irtmnta alb as defined by the Bay Area Nr pp
Q. Ilty Management Distad BOILFR-COMP OLTP OR 100,000 BTU) A D
4Yea o
havcreadthehaza oUs materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Ca'ornla Healthh5alety Code,Sections 7550.5,25533 and 7553d.1 ®En 26 1/10'1
un t dthat lithe builds docs notamently have atenanL that ltlsmy
NEW RESIDENTIAL MECH. SQFT. V VV Ix7xJN
r ors' llityto dlfythe pant o( he u ementnwhkh mustWmet
rt lsauan ofaCe pan
crlr uF: cuptrl]IVU
or authorized age t DateYW
TOTAL: ISSUED BY: do �-
OFFICE COPY