21476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProtect Identificationowner` - PERMIT NO.
Building Addms: J
3 �4nCw Z _ o7 21476
Phone.
CITY OF CUPERTINO-BUILDING DIVISION IIll
APPLICATION /PERMIT _lr!w40 Z
bn O BLTLDINGELECTRICAI PLUMBINC-MECHAMCAL CATFLORY CONTROLX
Arehlte /Enginaer. Lb.No:
QTy ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ N ❑I
LICENSED CONTRACTOR'S DECLARATION � `FX'L
I hereby affirm that am licensed under provisions of Chapter9(rommen APPUANCESRRSIDENrT1AL
Ing Mth,vvdion7000)of DlWsim3ofthe Bupnessand Pro(tWoneCode,and JOB DESCRIPTION
my
license la In full foss and effect. . PANELS
-
Flom.Clam LIcX
Date ContractorIM TO 2DOAMIS
ARCHITECTS DECLARATION 201-IOW AMPS
r�Q�yO (understand my Plans used sa public remNa OVER]OW gMPS SQ:Fr.FLOORARF_A $/SQ.Fr.
�>—U(�j Licensed Professional - SIGNS ELECTRICAL
res'¢ OWNER-BUILDER DECLARATION SI'ECIALCD(C[BT/M1SC
Xtp. � Ihereby affirthat(am exempt fromthe Contractors License Law for the
O Z J (olbwing reason.m ract
Carodon 70315,Business and Profession°Code:My dtyor
F2 ..tywhichrequlmaperMttomrulmct,alter,lmpmve,demolbh,ormpalr TEMP.METER OR POLE INST. �
anystructureprlortoltabsuance,alsorequlrestheappliantforsuchpermitto
file a signed etatament that he b licensed pursuant to the provisions of the ppWgg DEVICES
3$V, Gntoctorb Llceme Low(Chapler9(commencingwith Sectlon7000)o(DIW- ' 'I
pon3o(the BusinmmdPmfessloro Code)Orthathe Geumptthemfmmand SWIMMING POOL ELECTRI �' ,` �•. VALUATION
the brant for the allegedsubjects
tWexemption. Any violation of nalt o not co by any OUTLETSSWITCHFSFIXTUR Ir' (,..
❑
applicant dredapermit$ubjMsthe app0unl laatlWl penalty of not momthan 16 I:_
live hundred dolowner
of (e pm O
❑I,asownera(theproperty,or rtry employees withwages r their sole NEW RESIDENTIAL ELFDTR IIA7 ,FT,or TYPECON5IXUCTION
C < com(See.7 KBuldo the ess and rt,Pt lemaicnd Cod,:Th.CHntendedo License L w
$' ❑ ale(not 704y Business and of property
Code:TM1e Contractors henem law
5� docs not apply torn imsero(prough his o Wildnem oy mprovntherearyand
uch
who dcesmuchants amrkhlmvededorwgh Meownemp,howervrovlded that ilding or OCC.GROUP RFS.(IMT$
Improvementsarenot Intended d eirofcmplroffered iomth,h nee r,ihebrwilI have NOTAL:
improvenentbsoldwithlnomycirofcomplpbrytheawnerbullderwlll have
tliLturden O(FrovingthW he did nabulld Or bnpmve(orpurpoaeo(ule.). QTy, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively mneracting wBh licensed FTAODZDNE APN
contractors to construct the project(Sec.70K Business and Profenbm Code: PERMIT ISSUANCE �„
The Contractors License Law dm not apply to an owner Of property who
Wilds or Improves thereon,and who contracts (w such ptojeem with a ALTER-DRAIN&VENT.WATER(EM
cgpllector(s)licensed pursuant to the Carnotite',License Law. FEE SUMMARY
l�I am exempt under Sec B &P C !or this rcawn BACKFLOW PROTECT.DEVICE
Owner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_ -
WORKMAN COMPENSATION DECLARATION RECEIPT X
❑I hereby a(((rm that I have a certificate of consent to ulf-Insure,or a FD(TNRES-PER TRAPSCHOOL TAX Y N
ariflate ofWorkers'Cwnperuatim Insurance ora addled copythermf(Sec. RFLEB'T X
moo,lab C.) GAS EA.SYSTEM-1 INC4 OUILEM PARK FFli Y N
S
Policy N RECEB'T M
Co
m yed GAPA.SYSTEM-OVER BUILDING DIVISION FEES
Ce11Ncopy b hereby Nmiahed. _
ccrtlnea copy is filed withthe city inspection division. GREASE/INDUSIRLWASMINTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
"COMPENSATION INSURANCE
(This sectlon need not be completed if the permit is for me hundred dollars SEWER-SANITARY-STORM EA.2TOFT. Date Recei t#
(5100>orlessd ENERGYFEE Y N
Icertlfy thatinthe PersnIanymonsek(o awhich stobco pesubjec issued, WATER HEATER W/VENT/F].ECTR
I shall not employ any person In any manner a0 u to become subject to the
Worked Compewtlon laws o(Gllfomn
la.Dale WATER SYSTEM/TRFANG PAID
Z ApplicantZ ONOTICE TOAPPLICAM:If,aRermakingthbCertlflalea(Exemption,you NEWRESIDFNTIALPLMB, SOFT. Date Recel t#
Fshould become subject to the workers'Compemallon provbbm of the Labor TOTAL:
N Cade,you muatlorthwith amply with each provlalom orehb permit hall be <]
IU 1 deemed revoked. BUIL12ING FEE
(L C CONSTRUCTION LENDING AGENCY
Z SEISMIC FEE
I hereby alamrthat there b a comtrocion lending agency(or the perform FEE
anmoflhework forwhichthb permit b Issued(Sec.W97,CIv.C.) TOT L:
V O lendeh Name ELECTRIC
PLUMBING FEE
ly Lenaer,Aaam. QTY, MECHANICAL PERMIT FEE MECHANICAL PEE .
O W IakifythaHhavereadthbappliatbnandetatethattheabovelnfomutlon
1 bcorrect Iagm tocomply with all city and county ordinances and pale laws PERMIT IS
FEES PAID:
N relating to building construction,and hereby authmIca representatives of this -
F Z ity to enter upon the above-mentioned properly for Inspection purposes. ALTER OR ADD TO MECH.
V — (We)agree to save,indemnify and keep harmless the Ciy of Cupertino Date R6 t#
agaWtliabNtl , men psandeapnnseswhichmayinanywayaame AIR HANDLING UNIT(r010,00o CFM7 SUB TOTAL•
agalmt i ro ence the gran ling of this permit.
_
Z AIR HANDLING UNIT(OVER I0,0WCFM) CONSTRUCTION TAX
(gnaw of ant/ on actor Data allAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBant
or building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12•and the Date Recei t
Flea llh and Safety Code Section 25S32(a)7 HEATING UNIT(OVER 100ME
000 BTU) TOTA
❑Yes No-
Wllltheapplicantw tore building occupant use equlpment or devices ' FAN(SINGLE ISSUANCE DATE
which emit hazardous air contaminants as dell next by the Bay Area Airp�
Quality Management District? R'OR 100,000 BTI]) y— B p
4 Yes n❑No 6/
have read the hazardous maleriab rXqulremanH underChapler G95ofBOILER-COMP BN)
the Califomla Health&Safety Code,Sections 25505,25S33 and 25534.IAP
undeoland that lithe buildingdces net currently havealenan4 that itbmy' L MECH. SQ.FT. "'• 27 �(10ym`POmibility to nilly the occupant of the requiomenta which must be metCIIr s7J(prior to Lssua nee of a Certificate of Occupa racy. 1 U!•Owner or authorized agent DateISSUED BY �
TOTAL:
OFFICE COPY