21770APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldin Pro'M Identification 7
Building Address -
PERMITNO.
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G I I I/ O
wners one:
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
iiONSUb?vfliiALDATE
Contra r'@Name: r Lie. No:
BUILDINC-ELECTRICALPLUMBINC-MECHANICAL
CATEGORY
CONTROL X
Architect/ ginar. Lle No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
,LL
Address:'- S. -iA
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provloons of Chapter9(commenc
lng�tJOB
license is In full forte rad cited
DemshEeRit�l al's 0)of Dlvision3o(the Busin Cade, and my
LlrenseC LkX
APPLIANCE -S -RESIDENTIAL
DESCRfITION
PANELS
Da Contactor OA IN
— UP TO 2DO AMPS
701-IODDAMPS
ARCHITECTS DECLARATION
I understand my plans@hall be used as public record&
OVER1000AMPS
SQ.FT.WADRAREA $/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
�Y V
SPECIALCRCUIT/MLSC
DECLARATION
OWI am exempt
I hereby affirm that I am exempt from the LARAetnr@ Llrenz Lw for the
O /�
TEAR METER OR POLE INSL
pOWERDEVICES
following reason. (Section 70315, Business and Profe alons Code: Any city or
county which requires permit to construct, alter, improve, demolish, or repair
any structure prior to Its Issuance, also requlm the applicant for such permit to
file a signed statement that he h licensed pursuant to the provisions of the
J
SWEdbBNC POOL ELECTRIC
Contractors Lie... Law (Chapter 9(corrrrw. ng with Section 700D) of Divi.
shm3 of the Business and ProfessionsCode) orthat he h exempt therefromand
7r— rT
A ON
the bash forthe alleged exemption. Any violation of Section 70DIZ by any
appBcent fora permit subjecta the applicant toa civil penalty of not morethan
OUTLEISSWITCEIFSFIX'TURES
T E R
NEW RESIDENTIAL ELECTR
five hundred dollars ($500).
M I, as owner of the property, or my employees with wages as their sole
compon@allon,willdothe work andthestructure Is not intended or offered for
6SIO/9[S
TYPE CONSTRICTION
@ale (Sec 7064, Buslmss and Professions Code: The Contractor@ Ltmrue Law
does not apply b an owner of property who Wilds or improves thereon, and
who does such work himself orthruugh his own employees, provided that such
OCC. GROUP
RES. UMTS
fmproveonenis are not Intended oroffered for sale. If, however, the Wild Ing or
improvement is sold within ld within oyearofcompletlon,the owner-bullderwRl have
TOTAL;
t)19.L.Men of proving that M did cot Wild or Improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with Ilrensed
contractors to construct the pmJect(Sec. 7056, Businessand Professions Code:
QTY. PLUMBING PERMIT FEE
----I7.00D
� PERMIT ISSUANCE
ZONE
APN
The Contractor's License Law does nM apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ojecte with a
c.ffctor(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B & P C for this reason
ALTER -DRAW &VENT- WATER (8A)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT Js
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have • certificate of consent to self -Insure, ora(TURES
rtificeteof Workers'Compev timlw mnreoracertifledmpythemof(Sec.
Policya .> t'�SOO ^
Po11ryX f�Q�
FIDPER TRAP
SCHOOL TAX Y_ N
RECEIPT I
GAS FA.SYSTFbf-1 INCA OUTLETS
DANK FEE Y_ N
RECEIPT It
GAS EA. SYSCEM-0VER6(EA)
Conmpany QT7
BUILDING DI VISION FE ES
f I Certified copy Is herebyfurnished.the city
Irl- Certified copy h flied with the city inspection divialon.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssection need not be completed U the permit h ra for ohundreddollan
PAID
Date Recel tq
SEWER-SANCTARY STORM EA. 7(017.
WATER HEATER W/VENT/ELECTR-'
ENERGYFEE Y N
($100)orless.)
I artily that In the performance of the work forwhlch this peril is issued,
WATER SYSTEM/TREl1TING
I shag not employ any person In any manner @o as to become subject to the
WwIx n'Compeasatmnl'wsof Califomh. Data
PAID
Applicant I
NOHCETO APPLICANT.- H, after maWng thio Certiflote of Exemption, you
Date Recef of
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
should become cubed to the Workers' Campensatlon proal Ions of the Labor
Code, you mu at forthwith comply with such Provide. or this permit hall be
deemed revoked.
B E
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IhembyafRrm that there h m
a construction lending agency for the perfor
ance of the work for which this permit is Issued (Sec 3097, Civ. C.)
Leaders Name
Lenders Add mss
I malty thatl have read thisappliationand a xtethatthoabovelnfmnnatlon
is correct. I vgrectocomplywlthall etyand countyordinancesand state laws
TOTAL:
r
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL PEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authodu representativesof this
edy to enter upon the abovo-mentioned property for Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cu pertlno
against liabilities, }adgments, costs and expenses which may in any way acme
agabestsald City In c?oe�sequ�enre �of th�e gr�anting of this peril.
a -I--4 I.
ALTER OR ADD TO MECH.
Date Recei tN
AIRHANDLING UNIT (T010,ODOCFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER IO,ODOChM)
CONSTRUCTION TAX
Slgra me of Appllant/Contractr Date
EJ(HAUSTHOOD(W/D(C'q
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEA TING UNIT (TO t 00,000 BT U)
Will the applicant or future building occupant store or hand le hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Health and Safety Cade Section 75537(&)7
❑ Yes MN.
Dale ReCei tN
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE BIRD)
ISSUANCE DATE
Wlllthe applicant or future building occupant use equipment ordevices
which emit havrdous air contaminaecus defined bythe Bay Area Air
Quality Management DIstdd7
4yes ❑❑ No
93Q
0
BOILER -COMP OHPOR 100,000 BTU)
BOILFR-COMP(OVER 100,000 BTU)
bave ad the hazy dous materials requirements underChapter 6.95 of
the Glifomla Health& SafetyCode, Sepions75505,75533 and 75534. I
understand that if the building does not currently have a tenant, that it h my
h ��^
Y yC
NEW RESI DENI1AL MECH. c.Q.FT.
reepomoccupantlbllity to not ify the occupant of the mqutorments which most be met
,
'
prior to ana of a Certificate of Occupancy.
Owner or aull,mme, agent Dae
ISSl1ED
TOTAL:
OFFICE COPY