21774 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE OINT PEN ONLY
Building Peoed Identification PERMIT NO.
Building Addres: f 21774
nems ante. one:
CITY OF CUPERTINO-BUILDING DIVISION
(� Contraore Name: Lic.Nox APPLICATION I PERMIT CIP 1
BUILDINGELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL#
Architectneer: Lk.Na:
� QTY ELECTRIC PERMIT FEE BUILDING PERM—IggT INFO
Address I #9. - PERMITISSUANCE ❑ q�/i
LICENSED CONTRACEOR'S DECLARATION
Iharebyaffbm that lamlkmseduMerpro Wonso(Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwdh Sedion7000)of DivlYon3 ofthe Buslnessand ProfesslonsCode,and my
license lslnm taros anaeffea. rANEfS
License Clam LIC# W� i�•�•7'��
Date Contractor -�
ARCHITECTM201 IODO AMPS
SDECLAOVER 1000 AMPS 9Q.FL FLOOR AREA •$/SQ.Fr.
reO zp I understand my plata shat W used a mmrd public records
Fi d6 Llcon.ed Professional SIGNSELECTRICAL
<Q OWNER-BUILDER DECLARATION SPECIAL CIl2Cf11T/ML9C
Ihemt„ owing raferm thatlamexempt fromthe.i.a..ContradProfdorb License Law fort he
fo0owlwhichmnquimaon7071S,Bualnen andr, fpmve e=lCode hnydtyor TEMP MEFFE OR POLE INST.
f" cauntywhlch requlroapemdl tocorotruct,ilmr,Improve,denmlkh,orrepilr
S� anystruature priesto Its kauance,also requlrestheappgontforsuch permit to
d1 file a signed statement that hes Is licensed pursuant to the provisions of the EWER DEVICES
Q6 0 w$ Contractor's License law(Chapter 9(commencing with Section 7000)of Dial- SWIMMING POOL ELECTRIC VALUATION
F,30 amn3ofthe Businemand Pr femiov Code)orthat heisexempttherefromand
6 the bask for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURES
applicant fora permit subjectstheapplicant to a civil penalty of not more than
O Ove hundred dollars($500).
E]L as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
mm(Spenul[on,wOidothe work and thestrocture k not Intended or offend for
pInk ec.7014,Business and Profeans loCode:The Contradoe.License law
P',I $ does not apply man owner of property who Wilds or Improves thereon,and OCC.GROUP RFS UNITS
0. whodorsuchworkhimselforthrough hlsownempleyees,provided that such
Improvements are not Intended oroffemd fwule.If however,thebuilding or TOTAL:
Improvement ksold withinoneyearo(compldior4 theowner-buBderwlll have
t4Lkurden of proving that he did not build or Improve for purpose ofukJ. QTY, PLUMBING PERMIT FEE FLCODZONE APN
j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '
contactors to construct the pmjed(Sec.7014,Boah,..ed Professions Code:
The Contractors License Law does not apply to an owner of property who
Wilda or Improves thereon,and who contracts for such Ixejeds with a ALTER-DRAIN k VENT-WATER(EN
FEE SUMMARY
,nty'actm(a)Bmnsed pursuant to the Conendors License Law.
LJ I am exempt under Sec B k P C for this reasnn BACK FLOW PROTECT.DEVICE
OUTSIDE FLI'S
DRAINS FLOOR RODE,AREA,CONED. SANITARY Y N
Owner Date RECmrr#
WORKMAN rt, COMPENSATION DECLARATION �.���.�P SCJ;DOL TAX Y N hereby affldn that I have ve a•comcertificate of consent to self-meure,ora RECEIPT M
380000,,Labab
38CJ S ofWarken'Compeuatlonlrounn¢oramrtBkd copythereo(�ec. GAEA.SYSFFM-1 INCA OUTLETS PARK FEE- Y_ N_
Policy �'�� `CIS Q DING DIVISION
Com ones CAS EA.SYSI'FM-0VER4(PA) BUILDING DIVISION FEES
Certified copy k hereby famished. CREASE/EJDUSIRL WASTE INTERCEPTOR PLANCIiECK FEE
_
C.0ified copy k filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SE1YpA-gA�•,3gy-sloRM EA.iom7. Date Recei t#
(This section need notbe completed tithe perndt k forme hundred dollars
($1(A)celem.) WATER HEATER W/VENT/F3.1:CTI2 ENERGYFEE Y_ N_
I certify that In performance perfounce o(ihewerk forwhkh this permit is Issued,
I shall not employ soy person In any manner n as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation laws of Callfomla.Date PAID
OZ Applicant NEW RESIDENTIAL I'LMB. SQFf. Date Recei t#
'Z NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become sub),ct to the Workers'Comperuat ion provisions of the Labor TOTAL:
N Code,you=at forthwith comptywith such provisions or this permit shall be _ BUILDING FEE
W > deemed revoked.W m
— CONSTRUCTION LENDING AGENCY SEISMIC FEE '
CL
G I herebyafOrmthat there k a construction kndogagenry forthe perform, ELECTRIC FEE
7Z ' ance ofthework forwhichthk permit k Lwud(Seo 3097,Civ,C.) !CFM)
7FEE
00 Lender.Name PLUMBING FEE
LL I— Lender's Addre.s QTY. MECHANICAL PEMECHANICAL FEE
U I certllythatl havereadthk appBcaOonand Yatethattheabove Information FEES PAID:
O W kcorred.l agree to comply with all cityand county onlInanm and Yate laws PERMITI.SUANCE
} 1 relating to Wilding coutrudion,and hereby authorlu representatives of this
N ALTEROR ADD TU MECH.
F Z
city to the,indemnify
an
propertyharm) Inspection purposes. Date ReCCI t(f
4 —
against
agree to ave,Indemnity and keep harmless the City of Cupertino AIR HANDLING UNIT(TO 10,00
agaWt BabWtles,jtdgmenb,coYsand expenses which may in anywayacave SUBTOTAL:
aga bat said City In consequence of the granting of this permit CONSTRUCTION TAX
AIR I-v,NDUNc uNlr rovFx 10
Signature of Applicant/Contractor Data D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,ODO BTU) Date Recei tit
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Sanity Ccd9,.�edlon 75537007 HEATING UNIT(OVER 100,000 BTU TOTAL:
_❑'Yes bJrCIT No -
�� Will the dPplham core Wllding occupant use equipment or devices VENTILATION PAN(SINGLE RESIU ISSUANCE DATE
which emit hazardous air coots miants as defined by the Bay Area Air BORER COMP pE1P OR 100,000 BTU
ality Management Dktrict7 tl Ro
1�+� Yes No Irk®
`p (have read the haza�ous materials re Euhemenk under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU
the California Health A Safety Code,Sections 75505,25533 and 75534.1 - FEB
understand that if the Wilding does not currently have a tenant,that it k my NEW RESIDENTIAL MECH. 1991 SQFr. r 1 1
responsibility to notify the occupant of the requ demeans which must be met
prior to[ssuanre of a Certificate of Occapanry.
Q] y 11 m
Owner or authorized agent Date TOTAL: ISoUF
OFFICE COPY