21783 AFFLIUAN I I O FILL IN INFORMATION WITHIN RED LINES USE BALL POINT Pent UNLY
Do lldit Prefect Identification PERMIT NO.
B°°ding Ad°ren: 21783
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ncra ame: one:
Mix CITY OF CUPERTINO-BUILDING DIVISION
Contra .Na . LI No: APPLICATION 1 PERMIT 3
AAA
D BUILDWGELECTMCALPLUMBING-MECHANICAL CATEGORY CONTROL M
Architect/En r.
Lie.N.
1 L1 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address , L)'-' PERFETISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
IhthSyiflrmthat lamlicense under provisions
andPffhmsrode, mdn PANEAPPLILS CFSRESIDENTIAL ]08 DESCRIPTION
IngwlthSM1on7000)ofDIv1Yon3o(the BuYnesaand ProfesYonsCode,and
Ilttnse le In w1Lforce d affect a PANELS
Llmnsc C an`' Lt.N5 _
Date Cmd actor R c —UP TO 200AMPS
ARCHITECT'S DECLARATION 201-IODO AMPS
icZ i understand my plaru shall be used as public records. OVERIODOAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
ggq0
Licensed Professional SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
I hereby affirm that I am exempt fromthe Contractors License Law for the
C, following reason(Section 7011.5,Business and Professions Code:Any city or TIDM METERORPOLEINSr.
ccunly which requires a permit to comtrod,alter lmpwve,demolish,or repair
anyslrudurepr to Rsfssuance,aleorequlrestheapph.tfwsuchFw Jtto POWER DEVICES
file a signed statement that he b Ilmnse pursuant to the provbloro of the
Contractor's License Law(Chapter 9(cemmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O Yon3ofthe Buslnessand Professions Code)orthatheberempttherefmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILE75SWITCFIESF[XTURIS
eppBrant fora permit subjects the applicant to a civil penalty of not more than _
five hundred dollars($5D0). I NEW RESIDENTIAL ELECTR SQTT. STORIES TYPE CONSTRUCTION
F11,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Is not Intended or offered for
OIsle(Sec.7094,Buslnesa and Pro(esslom Code:The Contractors Licome law
$ don not apply to an owner of property who builds or lmpro e,themed,and OCC.GROUP, RES.AMTS
EE who daessuchwork hlmselforlhrough hisawnemployees,provided that such
Improvements are nm Intended oroffered fores x.If,however thebullding or TOTAL:
Improvement bsold within omyearofcmnplelb theowner-buBderwUI have
t"rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE F=DZONE APN
LJ L as owner of the property,am exclusively contracting with license PERMIT ISSUANCE p�
comradas to conslrud the project(Sec.7044,Business and Professions Code: 1 ( 9.00
The Contractors Lt..Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contra Cs for such ptojects with a FEE
MMARY
c9Wedm(s)Rmnaed pursuant to the Contractor's Lim..Law: BACK FLOW PROTECT,DEVICE —OUTSIDE
EFEES
Ll l am exempt under Sec B&P C for this reason
DRAINS FLOOR.ROOF,AREA,GOND. SANITARY Y_ N_
• Owner Data RECFR'TN
WORKMAN COMPENSATION DECLARATION PIXT[RiE4 PER TRAP SCHOOL TAX Y_ N
Merely af(Irm that I have a cortlliote of consent to self-Insure,ora RECEIVE N
cartificat..Wu lumi,Compenelion Insura qaoracertiflempythereof(Sec. GA -EA.SYSTEM.1 WC.40UTLMS PARK FEE Y_ N-
311 05�34� J
--EIPT N
Policy N
C
GAS EA.SYSTEM-OVER 4(EA) BUILDING DIV]SION FECS
edified copy is hereby furnished. PLANCHECK FEE
edNed copy b filed with the city inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEM PITON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-S10RM EA 2MFT Date Recei t#
(this section neednot he completed If the permit b for one hundred dollars
($Im)orless.) I WATER HEATER W/VENT/ELECTR (7Q ENERGYFEE Y_ N_
I mrtify that In the performance of the work for which this permit Is Issue,
1 shall not employ any pa.In any manner so as to become subject to the WATLR SYSTEM/TREATNG
Workers'Compensation laws of California.Dam PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQFr. Date Recei t#
Z NOTICE TO APPLICANT.ILaNer making this Certlfirate of Exemption,you
should become subject to the Wmluma Camp..tt n powlslona of the Labor TOTAL:
dq Code,you must forthwith mm ply with such provisions mthb permit shall be 13UILDINC FEE
deemed revoke.
W . CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Z ,Iherc affirmthat there b a mrutruction lendin a e forlhe erform ELECTRIC FEE
�' . B racy P TOTAL:
7 2 scam o(the work for which thio permit bbsue(Sec.3097,C1v.C.) � ��' s PLUMBING FEE "
V O Lender's Name
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O I mnifylhatl have madth6appUmtlonand Yatethattheabove Information -
O W bcormC.I agmeto complywilh all cityand countymdInances and Yate laws PERMIT ISSUANCE FEES PAID:
} n' relating to building construction,and berebyauthorim representativesofthb
I•' N city to enter up ALTERORADOTOME-CH.
_ Z Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of CupedlAO
ywaya crus SUBTOTAL:
L.I agaWtlbbllltln,jadgmenn,mttsand expenseswhich may in anywayadroe AIR HANDLING UNIT(TO 10,000 CFM)
agabut said City in consequence of the,g�r�antifn�g of this permit CONSTRUC CON TAX
[f�,Q3--(.7 ! AIR HANDLING UNR(OVER]0,010CI1eD
Signature of Applicant/Cmd-L or Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTA Date Recei t# rrrr..����
material
and Safety by the Cupertino Municipal Code,Chapter 9.72,and the }TING UNIT 100,000 BTU) TOTAL: .W
liealih. Safety Cade t^No 75532(x)7 e
Y. cT??Irr VENTILATION FAN RESID
Will the applicant meddroing as deficti by the Bay Area
devices ) I$$Uyy-ABTE
whichemitnagemente airrict? nbadAne by the Bay Area Atr Rn''�/
Quality Management DIaWC7 BOILER-COMP OTE'OR 100,000 BTU]
4 Yes �)'o p BOLER•CONP(OV{R100, DOBN IiAA Y 2 21991
have read the hazaatfddauamaleriab requirements under Cha er 6.95 of
the California Health&Safety Code,Sections 25505,25533 and 25534.1 i
understand that if the building does not currently have a tenant,that it it my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which moat be and ty UpprC,n
prior to Lssuarm of a Certificate of Occvpa my. CC
,rc� 3—IS—ql
Owne OM.flu dud agent - Data TOTAL: ISS, D,B
OFFICE COPY