21835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
1
Building Address:
2o t) o /�i/ - Y 1 R a�S
V V 5
ners,]pv: one: —7TPCrl7XTf8ITVMI 1-1 AL UA IL
6N 7 CITY OF CUPERTINCLBUILDING DIVISION
ContractorsNa : U.No: APPLICATION /PERMIT
BUILDINGELECTMCAI PLUMBINGMECHANICAL CATEGORY CONTROL 0
Architect/Engineer. Lie.N.
QTY ELECTRIC PERMIT FEE BU DING PERMIT INFO
Address: PERMITISEUANCE11 El ❑
LICENSED CONTRACTOR'S DECLARATION -
Ihereby affirm'hat l am Hemeed under provisions of Chapter 9(commenc APPUANCESRFSTDENFIAL JOB DESCRIPTION
ingwilh Section7000)of DtW.ion3oflhe BuMw andProfeasionsCode,md mylionove �S
Licans le la full(ores and effect. PANELS
Data Clan Lle p
Date CIHITE or UP TO 2DO Mrs
p1-IODDAMPS
ARCHITECTS DECLARATION
N o 2 I understand my plana.411 W used u public recede OVER IOW AMPS SQ.FT.FLOOR AREA -5/SQ.FT.
O
6%�E Licensed Professional SIGNS ELFfTRICAL
<<In OWNER-BUILDER DECLARATION SPECIALCIRCUTT/MISC
Thereby a(Orm lWtlamexsmp'fromlhe Contra
KRors License law for the
following reason.(Section 70315,Business and Professions Code:Any city or
F. TEMP.METER ORPOLE INST.
county which requires a permit romtutruct,alter,Impmvq demo Wh,orespalr
Oanystmu mpr rtoitsismance,al3orequimtheapphuntforsuchper.ltto POWER DEVICES file a signed statement that he Is licensed pursuant to the provisions of the
Contracmrs License Lsw(Chapter 9(conemencing with Section 7000)of LTM- SWIMMING POOL ELECTRIC �V�ALU^ATION
X 01 sie basis fo Businne e d xemptionCade)orlation f lection MIS by and s ✓v V
0.•,77 the bean for the alleged jecuthlon. Any violation of naRbn not re by any OUTLEISSWITCHFSFI%TURFS
applicant fora pe.Nt evb)ecbthe applicant to•civil penalty door more than
five hundred delta.($500).$(k NEW RESIDENTIAL ELECTR SQ.FE STORIES TYPECONSTRUCTION'
I,as owner of the properly,or he employees In with ended as thele sole
C
compensation,will clothe Business,
P,endihes Code:Th na intendeda License
d for
Law
S O sale(Sec.apply
Business and Pm(®Ione who
b:The Connectors Llmme Law
r3$ does nonsuch torn owner d through his
Wlms orlmpcoovidedreoRand hat such OCC.GROUP RFS.UNITS
who provemuch am not himself or oraugh hbownemployees,If,howrpertheb ilding or
Improvement larenot Intended orrofc pldio.I(,h nee-buOder ill have TOTAL;
Improvement of Is.dd within he did ectbuild rim thee forPurpose
rpose ofsahave
'1(9jLasoner ing the of the property,am
buildarvely contracting
oaeofcense QTY, PLUMBING PERMIT FEE
LJ L cue owner tr the property,am exdu Busi Business
nd Pro with licensed FLOOD ZONE APN
cont.ctore to corswctthe project(Sec.7096,Buslnem and Professions Cade. PERMIT ISSUANCE
The Contractor's License Law don not apply to an owner of property who ALTFA-D N k VENT-WATER(FA)
Wilde or improv.thereon,and who contracts for such pRojMs with a
licensed pursuant to the Ccntrad&s License Law, l } FEE SUMMARY
c Lj I am exempt under Sec B k P C for this reason BAIX FLOW OTECT.DEVICE _ ES
DRAINS ROOP,AREA,CONDJ i S_yJTTARY Y N_ -
• Owner
Data _ : 1 RECEIPI'p
WORK MAN COMPENSATION DECLARATION FIX '��r 100 TAK Y N
FIIM hereby affirm that 1 have a certificate of consent to rel(-inure,ora RECEIPT p
.rtlBcete o(Workers Compensationlesurence or a certiluoi copythered fSn. GAS EA. STEM- II PARK Y_ N
3800,Lab C.) RECEIPT M
Po11ryY GAS F.A.SYSTEM-OVER 4(EA) — —
Cam ny , BUILDING DIVISION FEES
O(ZvrtiBed copy Is hereby furnished. CREASE/NIDUSTRL WASTE INTERCEPTOR PLANCHE•CK FEE
MCerti6d copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA XIOFI' Date ' Remi t# '
(Th[ssecilon need nal be completed(f the permit Is forone hundred r
dolla
($100)or lend ENERGY FEE Y N
IceAtfy that in the performance ofth ork fa whichthle perms [$Issued, WATER HEATER W/VEM/ELECTR
1 shall not employ a soon In an nee to e n eu a the WATER SYSTEM/TREATING
Workers Cgmpen�naw$ofG ya 1a. PAID
—
z
Applian NEW RESIDENTIAL PLMB. SOFT. Date Revel t#
Z O NOTICE'f� NT:lf ermaking Get P t of Exemption,you
Hshould become subject to the Worker'Compensation provisions of the Labor TOTAL:
V8 Code,you swat forthwith comply with such provisions orthis permit shall be BUILDING
W drena:d revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there lar construction lending agency for the perform TOTAL: ELECTRIC FEE
Z once of the workforwhkh lhIs permit Islaved(Sec.3097,Clv.Cd
U O Lmder.Name PLUMBING FEE
LL h- Lender'sAddre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertitythatl have read lhfsappHntlonand statethatlheabovelnformation
O W ,
a Iscorrect.I agreetocomplywith alldtyand countyoed[nancesand nate laws PERMIT LSSUANCE PEES PAID:
(D rclatingtobulldingmwWctlon,and herebyauthorize reprcsentativesoflhIs
H Z citywenterupon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeel t#
V against llablllleg Wdgments,co&send expend which may ie.eywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequenn of the granting of this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
S nahnreof AppHcenl/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllnnt or future building cccopantstore or handle hazardous HEATING UNIT(TO 100,070 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
HeaHhand Safety Code Ion 7Ix532(a)I HEATING UNIT(OVER I00,000 BTU) TOTAL:
F� It a
Niche emit
mrebuilding
eartsasdefioccupant itbytequipment eBayAradevlm VENTILATION FAN(SINGLERESH3) ISSUAN -QATE
whichheMe hazardous air ntaMmnts as de0ned by the Bay Area Air
Qualify Mawgement Dct7 BOILER-COMP p}I'OR 100,000 BPM Fg
Yn i
No C 4
4haveread the hazy us materials requirements under Chapter 6.95 of BOEER-COMP(OVER 101,000BTU) r99d
the Glifo,nU health k SafetyCode,SectWm 75505,75531 and 75534. I 1X7
understand that if the building does not currently have a tenant,that It 6 my NEW RESIDENTIAL MECH. SQFT
resporsib111ty la notify the occupant of t1h9requirements which moat be mel - Nha M
prior loissuy9ce MaCe Ifke of Ocgip6my. - aen�.,.. n
X �(/�/L Ip/// -211319/ �.
Ovi�eYb,.uhatixed#gcet Dan! TOTAL.- ISSUED BY:
OFFICE COPY