21460APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pw'en Identification
Building Address:loebed-
PERMIT NO,
f
21460
W e I
�}^ 0
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
APPLICA LION SUBMIT I A 717—
I —(��Li
Conractor'shlarde: Lie. No:
BUILDING ELECTRICAL-PLUMBING-MMIIAMCAL
CATEGORY
CONTROL p
Architect/Engineer. Lic. No:
ELECTRIC PERMTTg
BUILDING PERMIT INFO
blevQTY
Addreee:� ,r
PERMITISSUANCE V V
❑ 1:1 El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commeno
Ing with Section 7000) of Division 3 ofthe Business and ProfessionsCede, and my
luvrselain fulifermandeffect.'QAV��+p`}J/a{e{
License Clam LIc.B
Date Contractor
p.a
APPLIANCESRESIDENTIAL
1
PANELS
i i:UUP w
JOB DESCRIPTION
7
' 201-1000 AMPS
ARCHITECT'S DECLARATION k�
I understand myp la. shall be used as publierecords.
OVER 1000 AMPS
SQ. FT. FL AREA
$/9Q. FT.
J/'C'
Licensed Profemlo.l � I`I ��
OWNER -BUILDER, E LARATION
Iherebyaffimnthatlam exemp[lr��''te nlractor's License Vw(orehe
.following reason. (Section 70315, BuaGleh 'Profembna Code:6ny city 1.
cauntywhlchmqulresapermitfocoratructialtAi,ad, derrol: orrepair
anystmeure priorto its Issuance, also req,,1mAheappVcentforauch pemNt to
file a signed statement that he Is Ilmnsed: Pursuant to the pmvialoru of the
Contractors Licemelaw(CMpter9(mnirrerilfingwith SedW.7000)of Divi-
emn3ofthe Buslnusend Profemloru Code)orehat hebexemptthere(romand
the basis for the alleged exemption. Any violation of Section 70315by any
rura theipn
spph..t far a permdt.bjechtheappllcant to a civil penalty crisis dandle
five hundred dollare(S500). b ,5;.� 1"
❑ L as owner of the property, or my employees with wages a, Ih sok:
mmpe.ation,Mlldotheworkandthestmctdre Is kdended oroffered for
d : TM ontr,%or'f9 Llceve Iasi
sale (Sec. 7044, Buafness and Profemiom C'11""
,
t
$IGNSELECIRICAL
IAL CIRCUIT/MLSC /r
t I,TEMP. MEITR OR POLE INST. p�V
fpWpR DEVICES
SWIMMING POOL ELECTRIC
OU77.ETSSWITCHESF[%TURFS
VALUATION
NEWRESIDENTIALELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
dont not ..ch to an owner of propeky qho Ild�a 9r sea, P e Ed th ry and
in.
wprow.csuchworkhlmueQorthrough hijo empinyees, pr thshuIIdIng r
improvemerabso noHnlended oroffe dor "" thhoweve;uldr, ill have
ImprovemenHaeold withinoneyearof r' lon,the owner-bufiderwili have
t1p*nden of proving that he did not build or imp rove for purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to rorutruct the project (Sec. 7014 Business and Professions Code:
TOTAL: _a
OCC. GROUP
,
RES. UMTS
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractor's License Law does not apply to an owner of property who
builds or Improves themon, and who contracts for such pt,ojects with a
�q➢t d Lx) beensed pursuant to the Contractor's License I.
I_J I am exempt under Sec. B k P C for this reason
ALTER -DRAIN & VENT- WATER (FA)
FEE SUMMARY
BACK FIAWI'ROTECT. DEVICE
—OUTSIDE
FEES
DRAINS FLOOR ROOF, AREA, COND.
PER TRAP
SANITARY Y N
RECEIn N
Owner - Date
WORKMAN COMPENSATION DECLARATION
[]IFD(MRES
I hereby affirm that 1 have a certificate of consent to self
SCHOOL TA% Y_ N_ '
-Insure, ora
eadificam.fWorkera' Compensation Insurance ora credited copy thereof(Sec.
3800, Lab C.)
RECERrf 8
GAS EA SYSTEM -1
PARK FEE. Y_ N_
Policyp
- RECEB'Cx
Com any
GAS EA. -
BUILDING DIVISION FE ES
�Certlied copy U herebyfurnished.the city
Certified copy Is tiled with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIECATE OF UEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(This section need not be completed lithe permit E (Drone hundred dollars
(5100)oifyin
I certifying that in the performance 1. anof y
I or II not s oy eny� a on iI any manner so as to become sub)ect to the
mannerhe so as t whichthispesub jed to the
Appill at nsatitio f Il is. Date
A Iicant r
PAID
Date. Recei t#
SEWER -SANITARY -STORM E.A.20OFT
WATER HEATER W/VENT/E.ECTR
ENERGYFEE Y N —
PAID
Date Remi f#
- WATER SYSTEM/TREATING
NEW RESIDENTIAL P[.MB. SQFf.
NOTICE 70�MP A Letter ng this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Cade, you at forthwith comply with such provisioru mthly permit shall be
deemed revoked.
TOTAL:
BUILDING FEE
TOTAL:
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there V a construction leadingagenry for the perform-
ance of the work for which this permit is Issued exce. 3097, Civ. C.)
ELECTRIC FEE
Q
lender's Name
Lender's Address
I certifythat I have read this application and seats that the above Information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
iSotaerl. I dgree to comply with all city and county ordinances and state law,
PERMUISSUANCE
relating to building comtruction, and hereby authorize representatives of thio
city to enter upon the above-mentioned property for inspection purposes,
) agree to rove, Indemnify an d keep handless the City of Cupertino
ag i. IlabNtles,p rats, cone ar ex rases which may In any way accrue
a ins old City in ne uphce of 'e tingw this permn
I` pe K.
ALTERORADOTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
Date ReCel t#
P
SUBTOTAL:
AIR HANDLING UNIT (OVER 1000 CFM)
CONSTRUCTION TAX
SI .tore 1 pplt rat ntractor ate
HAZARDOUS MAT RIALS DISCLOSURE
IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or handle hazxrdoua
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ikalth and Safety Cost In. 25532(2)7
Rill
Date ReCel t#
HEATING UNIT (OVER 100,000 BTU)Yes
TOTAL;
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
theepplicent Nture building past use equipment or devices
which croft hazardous air'contaminanb as defined by the Bay Area Air
Quality Management t et?
4Yes
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
-
have read the haze Dias materials requ lrements under Cha pier 6.95 of
the Glifmia Health A Safety Cade, Sec Ions 25505,25533 and 25534. 1
y a� pQfj
NEW RESIDENTIAL MECH.. SQ.FT.
understand that if the building does not currently have a tenant, that it is my
resp 'hllity to no[ theompa o(th qulrementswhieh must erne[
y�1�
{do sE ✓ 1990
_
prlo t issuanceof rtifffatea o. ry. //jam
1 I
Ower a tlhorizFd' gent to
TOTAL: �iISSLEDuy.�VZ1'
OFFICE COPY