21275 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ert Identification - PERMIT NO.
Building Address: 21. 2 7 5
I010 1 �>Fs��
nems aces: one:
CITY OF CUPERTINO-BUILDINGDIVISION �B .�
• ContrZado .Name: (� LI=.Na: APPLICATION /PERMIT ((/
�JCI�1 BUILDING-ELECTRICALPLUMBING.MECHANICAL CATEGORY+ CONTROL N
Architect/Engineer. Lk N.
OTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMIT ISSUANCE _❑ ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION .If
Ihereby
tdi..7nllatl iv licensed ofthe usinestalanaof ChionsCommmmc APPLIANCFSRESIDENTIAL JOB DESCRIPTION
InenseiSection f0W)of DivWon3afthe Bueneeundl'mfeulonsCode,andm
Ll.. k in s force and effect p PANELS
Datanae Class GI C7 Lk.N t4.20gI -
Date Canttactar Cdi�C1�
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�vv a0 ZO 1 understand my plats shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
d•��j' Licensed Pr f—I.sl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C
71.., I hereby affirm that l am exempt from the Contractors License Law for the
gqqq
0f-11-wing mas .(Section 70313,Business and Professions Code:An or
I"ty county which rcquiresa pernotwcostruct,alter,improve,deolbh,ocity
TFMP'MEIT7R OR POLE INST.
m
3a anystmu mpriortoib Wuamc ab .q.l .theapplinntfarsuchpermltto
U file a signed statement that he to licensed pursuant to the provisions of the POWER DEVICES
Contradore License Law(Chapter 9(commencing with Section 7000)of DIW- SWIMMING POOL ELECTRIC VALUATION
BOJ don 3 ofthe Buslnessand NaesslonsCode)orlhat hela exempt therefromand
•77 the basis for the alleged exemption. Any violation of Section 70315 by any OVILETSSWITCHES)TXTURFS
O<S applicant fora perMtsubjects the applicant to a evil penalty of not mrethan
Q five hundred dollars(S ). SQ STORKS TYPE CONSIRl1CT10N
I,as owner of the property,or my employees with wage r IMk sok
NEW RESIDENTIAL ELFGTR _ .FT.
asale(Sm 0KBuldnshe work,sandPranCrheatmde;TheCst ContraIntenctors
O offered for
ole(Sec apply Boas owner
Professions Code:The C improves License Law
$
who ddoes oes
apply torn owner ofptrough who Wildaopovidees thereon,and OCC.GROUP BE' UNITS
EE whodaes suchwork Minielf ndedorwgredfwhis nhaemployees, ertheedthat ilding h O
ImprovemenIssuld ithmone earofcompl lo.the ner-r, ilderwdI have TOTAL: D
Improvemnntbuldwilhinoneyearofcompldion,lheosvner-WlWerwllllaave
UAIZurdenof proving that hedid not Wud or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
j_j L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.70K Business and Professiom Code: -
The Contractor's License Raw dm not apply to an owner of property who ALTER-DRAIN&VENT-W - (EA)
Wilds or Improves thereon,and who contract for such ppojects with a FEE SUMMARY
�R1Fadoral llansed pursuanttothe Cusbador'.Limn.Law. BACK PROTECT. CE
LJ I am exempt under See B&P C for this maven
Owner Data
DRAINS F7 R GOND. SANITARY RPOF N
WORKMAN COMPENSATION DECLARATION SCltOOL TA% Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,or a IM) RECEPF X
outificate of Wo,kua'C.pe.gkm lnsunnca ora certified copy thereof(Sec. GAS EA. - I .4 PARK FEE Y N
3800,lab C.)
Policy N RECEIVE X
C.�mPany GAS FA. 4 BUILDING DIVISION FEES
I l,ertlfied copy is hereby furnished. CRFAS R PLANCHECK FL•E
Certified copy b filed with the city Impection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' C PAID
.COMPENSATION INSURANCE SANITARY-SIO Date Recei t#
(This section need net be completed if the permit Is for one hundred dollen
($100)orless.) EffATERW TR ENERGYFEE Y N
I mr0fythat In the performance of thework forwhich this permit Is bard,
I shall not employ any person In any manner so as to become abject to the WA.I.IR SYSTEM/ TI
Wmkeme'Compenution Lswsof California.Dale PAID
O Z Applicant you NEW RESIDENTIA PLMB. SQJU. Date Rec'el t#
Z O
NOTICE beOMPLICt to the
ager Workermaking s'
Compensation Certificate of Exemption,wme ..
Fehouidou=a forth ithou Workers' s orchis permit s alt bo TOTAL:
(/) Code,yor coked.forthwith comply with such provisions or this perMtshallW BUILDING •E
W deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihemby affirmthat there bammtrudlon lendingagency forthe perfomry TOTAL, ELECTRIC FEE
Z anoc oftheworkftrwhkhthb permit b Issued(Sec.3097,Clv.C.)
(� O Lender's Name PLUMBING FEE
LL
F Lendee.Address QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
O W Imect.1hatlha)compl hbappliutknanduty ordinances
ffitorand
tion laws
1 lacoingtobgreeto camplywilh andhereb authorize
nanwand tlsofthie PERMIT ISSUANCE FEES PAID:
). W city to enter
Wildinge abovelorymddpropauthorize rcprcunpu rvea of this
HZ _
citytoto sav,Wve-menrl and
propertyforthe Cit purpose•. ALTER Oft ADDTO MECH. Date t#
(We)agree to save,indemnify an d keep harmless the In
Cupertino
against said City nconsecluence of the
expenses ranting which muyin anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) O
against City In conecquena o(th<grsnting d blab permit.
{-(�j�/r5•��'��.) tO�jZ��lO `uRHANDLING UMi(OVER IO,000CFM) CONSTR TAX
Signature of AppOont/Contractor Date EKHAUSTHODD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE IALy .I1/Y_D�
WIIltheappilca rat or future building occupant atom or handle hazardous HEATING UNIT(TO IM,000 BTU) Date s• Re&6i t#V
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Cade Section 75532(.)7 HEATING UNIT(OVER 10Q000 BTU) TOTAL:
Ye. No
Willenut appllanlor uNre Wilding occupant use theequipmentBay Area devices VENTILATION FAN(SINGLE IlESID) SLjA
whkheMthnardousair rict? enb as defined 6y the gay Arca Air - 'Il1Yl�e�BSX U
Quality Management District? BOILER-COMP OFI'OR 100,p00 8TU)
Yee No
have read the hazy oils materials requirements underChapter G95 of BOILER-COMP(OVDR 100,000 BTU)
the Califomla Health&Safety Code,Sections 2S505,25533 and 25534.1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MEIN. SQFP y
responsibility to notify the occupant of the requlrenents which must be met
prior to issuance of a Certificate of Occupancy.
bw (sVaaN
191a�90 BLDG, SPECTION DEPAR NIL
Owner or authorized agent Date ISSUED BY:
TOTAL: _
OFFICE COPY