21973 APPLICANT TO FILL.IN INFORMATION WITHIN RED LINES,- USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BueaAdd
_s Q 21973
CITY OF CUPERTINO-BUILDING DIVISION
Lic.No: APPLICATION I PERMIT
BUILDING-ELECTRICAL-FLUMBINC-MECHAMCAL CATEGORY CONTROL#
Amhlted/Engineer. •aa /��)44:5
Cid QTY ELECTRIC PERMIT ` F,E.aE� B///U���ILDING PERMIT INFO
Addre .v . l PERMIT ISSUANCE �,,,kya ❑
LICENSED CONTRACTOR'S DECLARATION
.I hereby affirm that I mEmnsed under provisions of Chapter9(commmo- APPLIANCES-RESIDENTIAL JOB DESCRRPI'ION
Ingwith Sect1on7000)of DlWslan f eBuslnnsand ro(esslonaCode,and my � q
Ilcense Is In(u o d died. •i. PANELS wl I-1
License Cle LIC#
Date car cto - rLUP TO 200 AMPS
HITS CIA IT
301-1000 AMPS
µQ!x kssahall be used as public records, - OVER 7000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Ez LI SIGNS ELECTRICAL �.p,
leu OWNER-BUILDER DECLARATION r - 2 gpp-CIALCIRCUIT/MLSC LR/ `
za, � I hereby affirm that I amexempt from the Contractors License Law for the I
(olio wing reason.(Section 70715, Any city or Business and Professions Code:
O 1:. TEMP METER OR POLE INST.
county cwhich lresa to,conamod,altepImprove,demb rrepalr
any3tmmpwtoiftaamealsorequsupt
file.signed stgemsmt that he Is licensed pursuant t the provisions of the
POWER DEVICES
Contractor.License Law(Chapter 9(comncing with Section 7000).f Divl-
Ion3of,heBunaandPoessionsAe)arthathesexmpttherefromand
SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESFTX'1'URE5
applicant fora perndt eubjectstheapplicant to a civil penalty of not more than
five hundred dollen(5500). NEW RESIDENTIAL EI.ECTR FT.
! L as owner of the roe _SQ.F1. TYPE CONSTRUCTION
�n ❑ p p rty,or my employees with wages as their wk
compensation,wRl dothe work andthe structure isnot intended or offered for
O' sale(Sec.7064,Business and Professions Code:The Contndots Llmras Law
r3$ does not apply to an owner of property who builds or improves thereon,and OCC CROUP RFS.UNITS
who does such work himself orthrough hisown employees,provided that each
improvements are not Intended oroffered fersale.IL ho vever,thebulldingor TOTAL;
improvement bbold withNoneyearofmmpldion,the owner-buBderwRlhave
tka.4urden of provingthat he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEEFLOODZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Professions Code:
The Contndor's License Law does nor apply to an owner of property who ALTER DRAIN&VENT WATER(EA)
Wilda or improves-thereon, and who contracts for such pTojem with a
cgatladoKs)licensed pursuant to the Contractors Llmnse Law. - FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE ETrq
Owner Date DRAINS FLOOR ROOF,AREA,COND. SAMTARY .RECEIPT#
ce
WOR COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self-0FIXTURES.nsun,or a •IIIRES.PER TRAP s CO SCHOOL fAX Y N
certificate ofWorkeri CompeneatknIs mc.or.certified copythemof(Sec. RECEIPT#
3800,Lab C.) GAS EA,SYSTEM-11NC4 OUTLETS PARK FFR Y— N_
Policy X GAS F.A.SYSTEM-OVER 4(EA) RECEIPT#
env '� -a '� BUILDING DIVISION FEES'
rtiffed copy b herebyth the cis. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
!,
pay
copy b flied with the city inspection dlvblon.
CERTIFICATE OF E%EMPHON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANTIARYSIORM EA 200FT Date Regi t#
(Thlssectbnneed nor be if the permitSURA is(mane hundred dollars
'!. ($100)mlem.) WATER HEATER W/VENT/ELECTR q �yJ ENERGY FEE Y N
Icortifythat in the performance of the work forwhich this porous is issued, is —
Ishall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREADNG
.j Wmkers'Compensathm Lawsof California.Date PAID '
O Z NOTICE - NEW RESIDENTIAL PLMB.__SQFL Date Recei t#
Z O NOTICE TO APPLICANT If,after making this Certificate of Exemption,you
Fshould become subject to the Workeri Compereation provisions of the Labor TOTAL:
Rh Code,you=atforthwith comply with such pmvialoos or this permit ahall be
W > domed revoked: BIJILDINC FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafflrtn that therefsa mnstmdion lendingagenry for the perform- ELECTRIC FEE
Z once of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: 7, a
O O ]ander¢Name PLUMBING FEE
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O,W ! Imdifythatlhavereadthisappliatlonandstawthattheabovelnformation -
1 ismrred.I agreeto complywlth all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
relating tobullding construction,and hereby authmim representatives of this
(_ Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date - ReCei t#
e)agree to save,indemNfy an d kee harMeas the City of Cu Nmoo - - p
O ata mmccru
nucoam..de whkhryinanywayae ATR HANDLING UNIT(TO 10,030 CFM) SUBTOTAL:
tss
tog his permit..—�`^
.. ja,? st. AIR HANDLING UNIT(OVER 1Q000 CFM) CONSTRUCTION TAX -
gnature o n o r J DGat�e! EXHAUST Hoop(w/Duca CONSTRUCTION TAX PAID:
HAZA O ALS DISCLOSURE
Will the applicant or future building oceupantslore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(s)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yea
NN.
Willthe applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air �a
Quality Management District? BO
TLEft-COMP OHP OR 100,000 BTU)
❑Yrs No
Ihave read the haza cus materials requlremcnis under Chapter6.95 of = BOILER-COMP(OVER100,000 BTU) pal/tp � ��
the California Health k Safety Code,Eedit1
ioru 25505,25533 and 25534. I MAR
understand that If the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to not Ry the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupa cry. CI}I/Of ftU
Owner or authorised agent Date TOTAL: ISSUEDBY: y✓�1�V v1'lYP'�s`-�"�
OFFICE COPY