21767 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:
3p 21767
ams: on - p AL DATI!
_ wfa CJTYOFCUPERTINO-BUILDING DIVISION
Contract° ams' Lm.No: APPLICATION / PERMIT eLU—1
BUILDING-ELECTRICAL-PLLTMBINC-MECHAMCAL CATEGORY CONTROL a ,
relit Riser Lk`No:
Ire QTY ELECTRIC PERMIT FE�E-a�� BUILDING PERMIT INFO
Add : b �W co�t Ctc- PERMITISSUANCE CXR
ED CONTRACTOR' RATIO - L{�
I hereby affirm that l am Licensed under provisions ofChap[er9(mmmm APPLIANCES-RESIDENTIAL JOB DESCRIBION
IngwilhSecHon70fA)of DlWalan3oftfie Buslnessand ProfesslonsCa1 y ���
license ie In fug force and effect. PANELS
Llce..Claes lc.#
Date ContraciorUP TO 2DOAMPS
ARCHITECTS DECLARATION 201-1000 AMPS
pQ±aO Zp I mimstand my plans shall be used as public rerorde. OVER 1000 AMPS SQ.FT.FLOOR AREA s�$//SSQ.FT.
E�
Unmixed Professional SIGNS ELECTRICAL - la]y� D ' ( 1' `I
< tCd OWNER-BUILDER DECLARATION
` ,�a SPECLILCIRCUIT/MLC
Z 12 owing --.(hat L am xempt31.5,B(ro en.ml raftsa rb.Cosa L y fonthe _ � � � �
poo qqqq =ntyng reason.(Section 7031.5,Builness and Professions Cade:h, ci or
Z q countywhlrh requlresapemdtrororutroct,ilter,lmprove,demoWh,arrepalr TEMP METER ORPOLE INSC.
O any stmcturetatemeite IssuanceLicensed rersuant to the rorisions of the POWER DEVICE �
file a signed statement that M R Licensed pursuant ro the provisions of the t U
uO,( Contractors License law(Chapter 9(commeneingwith Section 7000)ofOwl.
.:7} son 3 of the Buelneseand Profeeslom Cod.)millet he is exempt therefromand SWIMMING IDOL ELECTRIC ,r
the basis for the alleged exemption. Any violation of Section 7031.5 by any 0 a L rsyT
iS
applicant for a permit aubjectsthe appllcantto a civil penalty of not morethim Q�-El' �I�N%IUII� - S" C6 ` J s V-�lJ
flv�undred dollars($500).
QQQ I,as owner of the property, NEW RESIDENTIAL ELECTR SQFr. STORIES TYPECONSTRUCTION
�n p ork,a orhe employees r their
mm(See,70KBusiness work andthes Cods;Thructurs e
C Intended oroffered(or
O do(Sec 7014,pply to BusinessandProperty Code:The Contractorsr imporms% hera slaw
$
does not suchwanownerofpropertywhon empilds oyees,povide reatsuch OCC.GROUP RES.UNITS
m,and
w Improodconvements
workhimee dee orough ldeownle.If however,
wer,videdihatsoc r 1 ��as
Improvement issold intens yearfferedfarrele.theo e-bugderwfll ave TOTAL; lW
Improvemenibeoklwlthln oneyearo(complNlorytheowner-W BderwRltuve
the burden of proving that he did scot build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
onetraRos,to construct the project(Sm 70K Business and Professions Code: -
The Contractor's License law does not apply to an owner of property,who ALTER-DRAIN kVENTWATER(EA)-
Wilds or Improves therear,and who contracts for such plo - -
jects with a FEE SUMMARY
�gptTactw(s)11. and pursuant to the Contractor's License Law. gp�FLOW PROTECT.DEVICE
LJ I am ezempt under'Sm B k P C for this reasonOUTSIDE FEES
Owner ate
DRAINS FLOOR,ROOF,AREA,COND. SANITARY. Y_ N_
DRBCEIPI#
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certlRcete of consent ro self-Insure,or FIXTURES.PER?KRIS - SCHOOLTAX Y_ N_ ,
certifiateofWorkers'Compensation leu rencq gLacerifiedcopythereof(Eec. - RECEIPT«
1.3800,Lab C.) }N ni CJ rJ (�� GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polity p'• V fj L(J C RECEIPT#
OVER 4(EA)
Som ser /ford.. i GAS EA.SYSI'EM- BUILDING DIVISION FEES
erti0-ed copy Lc erebyth the ed.city ,,,T— — CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
elD Certified copy b(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAp PAID
_
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.200Ff. Date Recei t# a
.(Thlssetlion need Tat becompleted BUM permit b(or am hundred dollars
(Stm)orleae.) WATER HEATER W/VENT/ELSCTR ENERGY FEE Y N
Ill net hat employ
anhe y
e oftheworknynumner forwhlbeca permit is
I shall not employ eny person In any mifia. eo u to berorre subject to the WATER SYSTEM/TREATING
Worlicant mpensaRon Lowe of Callfomla.Date PAID L�
O Z Applicant NEW RESIDENTIAL FILMS. SQ.Ff. Date RCCA t# S�e
�Z G NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you D
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
F N Code,you mu at forthwith comply with such provisimu or thin permR shall be BUILDING FEE Cw
LU > deemed revoked. _
CONSTRUCTION LENDING AGENCY SEISMIC FEECL t O
M C Iherebya rklftrwhkhat thin perconstruction ed(Selending agency 7,Cly. .) perform ELECTRIC FEE
� Z once ofthe worktorwhkhthle permit bLssued(Sec.3097,Civ.C.I � TOTAL:
02 Leader's Name PLUMBING FEE
IL F Lender'eAddreas QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W ce
Irtifythatl havereadthls application and statethatthe above information
1 is rorreci.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. relating to building mwtruction,and hereby authorise representatives Of this
city to °the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
_ e)agree t cave,In.d.=an d keep harmless the City of Cupertino Date Receipt#
I� against llabNt dgmenh,rosts and expenseswhlch my In anyway accrue ALRHANDLINGUNRT( om000cirm) SUBTOTAL:
a abut sold ty consryu£n;of the granting of thin permit
Z/ AIRH&NDLINGUN1r(OVER10,11CFM) CONSTRUCTION TAX
11 Sigh. Leant/ o r Date EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOU ATERIALSDISCIOSURE -
IlltheappIleantorfutu wilding occupant store orhandle hazardous HEATING UMTHO 100,000 BTU) ,Date ReCeI t#
material as defined bythe Cu Bien Municipal Code,Chapter 9.12,and the
M Yen d Safety Cade,Se Jioon 25532(a)i HEATING UNIT(OVER 1011,000 BTU) TOTAL'
Wlllthe applicant or❑future building occupantuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air rontaminanb as defined by the Bay Area Air
nesManagement District? BOILER-COMP DID OR 100,000 BTU)
�iJ,Yrs n❑No
]Pave reed the hazardous materials requlrerrenis under Chapter 6.95 of BOILER-COMP(OVER I00,000 BTU) BO�
he California Health k Safety Code,Sections 25505,2S533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NE'WRESIDENMALMECH. SQ.FT FEB g U X991
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date jjj3!!!]]]��,ylsl�/s�t��(a) P17" b
ISSUED BY
TOTAL: W�l/tYf\�/'��`�`—'(/
OFFICE COPY