21963 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro en Ideml(Icatlon PERMIT NO.
Building Address: 21963
sera ams: e; .
'-1 — g CITY OF CUPERTINO-BUILDING DIVISION —q'�
cemrant .me: ueNo: APPLICATION I PERMIT
BNLDINGELECTRICAT-MUMBINC-MECHANICAL CATEGORY CONTROL Y
Arctitm/Engineer. Lk.No: ,
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addma: PERMRISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMreby SeLtIohmthafDimscm3ofthe ur msandPmfe am,r9(e and ATM1'LIANCESRESIDENfIAL _n tOpD r
Inense I.M1un force anDlvifect. (The Businnsand Pro(eWmsCode,and my
license Is In ni (oro:and effect. PANQS '
Llano C6®- Lk.Ycorr� 1
Date CL`c`# or_
UP TO 2DILAMPS
ARCHITECPS DECLARATION 201-10DOAMPS '
q�q�uu coO zzC I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
k�u Gcnnxd Professional SIGNSELECTRICAL ,
��6 OWNER-BUILDER DECLARATION SPECIALCIRCIRT/MIISC
z.�R; I hereby afgrmthatlameaemptfrom the Contractor's License Law for the
09o qqqq following reason.(Section 70'11.5,Business and Professions Code:Any city or
-, county which requires a permit to construct,alter,Improve,demolish,orrepair TEMPMETER ORPOLE INST.
S5 an yotmmmpdortolbi ame,atsorequimtheappHuntfw.uchpemdtto POWER DEVICES
15 1 Rla a signed Yatensom that he is llmssed pursuant to the provisions of the
4613 u,II.. Contractors Lica.law(CMpter 9(commencing with Section 7000).f Divi- SWIMMING IDOL ELECTRIC
�O;J Mon3ofthe Busi uses dPa.WmCode)orthathebemmptthemfmmand VALUATION
6.•,577 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWRCHFSFM7VRES
applicant for a permit subjectsthe applicant to a civil penalty of not more than
five F11,aso nWlarshepr. NEW RESIDENTIAL ELFGER SQFI. ES TYPECONSTRUCTION
�n ❑I,as owner of the property,or my employers with wage as tMtr sok
compensation,wBBoadnes, workandthe Code:The
Intended or offered for
doesO oak(See 7014,to as ow and f property Gude:TM C improves
License Law
�$ who not applytoan owner ofpropertywhobuildsor Improvesthercoryand
^ whodceseuchworkhimself orthrough hlsownemployees,provided that such OCC.GROIIP RLS.UNITS
improvements are not Intended oroffered forsale.I(however,lhebulidlog or TOTAL:
Improvement lasold within omyearofcompletion,tM owner-builderwill have
flic.Ilarden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
Lj 4 se owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
contnctm to mmtmct the project(Sec 7044,Business and Profmbm Code:
The Commences License Law dm net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilde or improves therms,and who contracts for such pkajem with a FEE SUMMARY
o7agacior(s)IkmctLimo
ds To rauant to the Contraoea Llme Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this reams
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_'
• Owner Date RECID'IN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a mrtirute of convent to self-insum,(S • RECEI'T N
380BI.1b C.Worken'Comperoatlonlmura2 oreu copy thertro((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE RECEIN
350Q lab CJ OCJ Cd
PollryY -- CAS EA.SYSTEM-OVER Com any BUILDING DIVISION FEES
Camfind copy b hereby fu ed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE ytiyVER-SAMT•ARY-STORM FA pBFI. Date Recei t#
(Thlssectlon need me be completed If the permit la forone hundred dollars
(5700)orlcss.) WATER HEATERW/VENT./ELDCTR ENERGYFEE Y N
lartifythat lathe pedormnanao(the work forwMch this pemdt is lsaed,
I shall not employ any person In any manner n as to become subject to the WATER SYS[FM/TREATING
Workeri Compensation Tawe of Califom a.Date PAID
Appllunt
Zthis NEW Rmorxnnt PLMe, sDFr. Date Recel t#
0 NOulCETO APPLICANT. fte� Certs,pro ofExemption,oftie Labor
Code, become forth to the Workers'such proalonprovbiomomits Lab or TOTAL:
N deemed
cket(rrthwlth comply with such provisions orthb perMtshell be 1 G
deemed revoked.
FEE
F3 CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Z IherebyafOrm that there is a construction lending agency forthe perform- TOTAL; r 1 �T}y�� ELECTRIC FEE
O arm of the workfor which this permit b kssued(Sec.3097,CIv.C.) `� .(')
Lenders Name PLUMBING FEE
1- Lender's Addrosa QTY, MECHANICAL PERMIT ITE MECHANICAL FEE
U I artlfythat l have madthiseppliution and Yatethatthe above lnfomatlon
W o ccrecn l agmeto complywith all city and county ordinances and Yate lawn PERMEr ISSUANCE FEES PAID:
IL relating to building construction,and hereby authorize representatives of this
N citytoenter upan the above-mentbmd property fce Inspection purposes. ALTERORADDTOMECFL
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei t#
against liabilities,judgmands,mYsand expenses which may lnanywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against ald Cnv In mnpacryence of the granting of this permit AIR HANDLING UNIT(OVER IQ000CIM) CONSTRUCTION TAX
Signature of AppRmnt/Contractr DaF)(FIAlJST HOOD r ` �oF 1 ' ' '+ CONSTRUCTION TAX PAID:
te
HAZARDOUS MATERIALS DISCLOSURE
Will theappuanl or future building occupant store or handle hazardous HEATING UNIT(TO 100,OID BTTA Date - Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9,12,and the
D Hee lth and Safety Code Ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:'
❑Yes
Willits hazardu mrebuilding ocmpandby tequipment he Bay Area devices VENTILATION FAN(SINGLE RE4D) ISSjJ-A'R'IaM�IIYR'afiTEtl'F'
which emit hazardous ntaminante as defined by the Bay Area Air
"Qu❑ality Managemrent District? BORER-COMP OHPOR 100,000 BTU) APR
� .f1 Yn No -
have read lheh malerlals requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BM
` 'the California Health&'Safety Code,Sao loss 75505,15533 and 25530.[
�rt� understand that if the building does not currently have a tenant,that it la my NEW REST DENTIAL MEIN. SQFT ��•�
mponsibility to notify the occupant of the requirements which most be met
prior to issuance M a Certificate of Occupancy.
II �,
� 3 d6-91
Owner or aulh dagent Data - ISS •D
TOTAL:
OFFICE COPY