21318 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proert Identification PERMIT NO.
Bn '01 e�54ell-;e n 21318
e aces: / one:
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a Z ,01a C_ CITY OF CUPERTINO-BUILDING DIVISION
• Contractors Name: LIc.No: APPLICATION I PERMIT C
Architect/Enginar, Lk.No: BUILDING-ELECTRICAlePLUMBINGMECHAMCAL CA7FfARY CONTRg614�S�
ELECTRICPERMIT FEE BUILDING PERMIT INFO
-1Add..- PERMTISSUANCE 'p
LICE N D COTCRDE�UKATI Kj f�Y
a�
I hereby•f(Irmthat l am 11censed under provisions o(Chapter9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sedion7000)Of Dlviston3ofthe Bue mmandProfeeslonsCode,andmy
license le in full form and effect. PANELS
Llcemr Chea Lk.N
Dale ContnRor UP TO 200 AM
ARCHITECTS DECLARATION
W0 Z I understand my plane shall be used a public records. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Licensed Professional SIGNS ELECTRICAL
6
OWNER-BUILDER DECUBATION
fn tfil hereby.ffiron that learn exempt froonthe Contractor's License Law for the
SPECIALCIRCNT/MISCowin � V/
02,oo (ountywmason.(Seatonrmitto ostnmand Proprove,fead s Code:Any city or
p.� TEMP.MEfIX ORPOLE INSf.
F� countycturshIch rcqulma Femdttomretnquire.theapmvgdemolbh,urrepalr
qqqq'''' anyawdure pdementahat he is also sed pursuant
suantt the ponuchperf tt a POWER DEVICES
14 Roe a actor'd statement that he t licensed pursuant it the provblO(f of the
3 u'G Contracture License Law(Chasalonser 9 ole)cucing with Section
mpIlle00)omand gyypt,VINC POOL ELECTRIC VALUATION
elOn3otthe Business Ind['rofmmroCode)orthat hehemmptthere(romand , q
6,5 the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
applicant for a permit sub)ecathe applicant to a civil Penalty of not more than7 �7
five hundred dollars I$500L NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION�n ❑I,as owner of the pmperty,or my employees with wages as their sole
mpeneatlon,will doths work and the structure isnot Intended or offered for
Dsale(Sm 70K Business and Pro(mlore Code:The Contractors License Law
5 does not apply to an owner of property who Wilde or Improves thereon and OCC.GROUIP RFS UNITS
who does such work himself or through his own employees,provided that such
bnpmvemenb arena Intended oroffertd(msale.lI however,thebuclding m TOTAL-
-I Prov rat heOId wilhinoneyearotcompldWmtheowner-WilderMll have
t ..o,.t ving that he did cert Wild or Improve for purpose ofsala). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
k as owner of the property,am exclusively contracting with licensed
contrscrom to construct the project(Sec.7014,Business and Professions Code: PERMIT ISSUANCE 1.aD6
The Contractors License doss not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffA)
Wild.or improves th and who contracts fm such peojec s with a FEE SUMMARY
ogglpenm(e)Il�ved ant tot Contractors License Law. BACK FLOW PROTECT DEVICE II._II pi er Sec. _, B k P C for this mason
Owners�e Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
RECEIPT N
OR O ENSATIONDECLARATION SCHOOL TAX Y N
❑I he Eby affirm that I have a artlflcate of consent to self-nsure,or a FIXTURES PER TRAP 1 0 a
mKif cede of Workera'Compersztion Irsumnce are anNed copytheteof(Sec. RECEIPT N
3800,1.6C.) GAS EA.SYSTEM-1 INC.40UTLEML, p PARKFFE Y_ N_
Policy N RECEIPT N
Com any GAS'F.A.SYSTEM.OVER 4(EA) BUILDING DIVISION FEES
ffCert10ed copy h hereby fumhhed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Cenlfied copy h filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID '7�Q
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recel tit tSI,A-p
(Thissectlan need not be completed If the permit h forone hundred dollars
($100)or ins.) WATER HEATER W/VENT/EI.F1:1R ENERGYFEE Y N
I arti(ythat In the Performance of the work forwhich thin pannit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Lawsof Callfomia.Date , 0'0 PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQFr. Date Recei tN 5tL(z
making Z NOTICE TO APPLICANT:If,after this Certificate of Exemption,you
should become subject to the Warkers Compewation provisions of the Labor - TOTAL:
N Code,you=at forthwith comply with such provhoors or this permit shall be U LPI l _
W > deemed revoked. -
13 CONSTRUCTION LENDING AGENCY SEISMIC FEE Z•
CL Iherebyaffirmthatthereliacomtruction lending agency forthe penomv TOTAL: �� ELECTRIC FEE .,7
Z
7 ance of the work for which this permit b Luued(5eo097
3 ,Civ.C.)
U O lender.Name PLUMBING FEE — lid
IL H Lendve.AddQTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcertifInformationatl have mad this application and state that the above Information
i.ameect.Iagreeto complywlth all chyand county ordi...reseed state law. PERMITISSUANCE .00 FEES PAID:
CL
relmingtobulldmg romwctl rad herebysuthorize rcpres<ntativn ofthh
F to citytuenter upon theaW tinned Property for Wpectle.Purposes. ALTERORADDTOMECH. Q
Z Date Recei tit
(We)agree to save,1 Ity an d keep harmien the Cltyof Cupertino
V against lhb s,judgV ,cosiest eme.vehichmayme.ywayattme AIR HANDLING UNIT Q010,000 CFM) SUBTOTAL:
agaWte tylnc uenm granting of tha'emalt. -
�„ �a AIR HANDUNC I>Hrr(OVER la,000cFu) CONSTRUCTION TAX
Slg tore pB rat C rat l c?^Dat`e EXHAUSTHOOD(W/DUC'p CONSTRUCTION TAX PAID:
DAlaI1DI SMATERIALS DISCLOSURE
Willt .applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0DO BTU) Date Recel tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Stolon 2SS32(s)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant m tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) SO ISSUON�Fa,pATE
which amt hazardous air contaminants as defined by the Bay Area Air I,A�U■®®
Quality Management District? BOILER-COMP DH P OR 100,000 BTI)
yes
No
(have read the har2us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) N(��( 31f,
the C.lifomla Health&Safety Code,Sections 25508,25533 and 25534. I Roy u
and erstand that if the building does not currently have a tenant,that It L.my NEWRESIDENTIALMECH. SQ.FT,
rrspomibcllty to notify the occupant of the requUnmo
ernts which at he met pypre dy.�. r�,s
prior to issuance of a Certificate of Occupancy. CIO P-fl'1Rg"M
Owner or authorized agent DateISSUEDBY:
TOTAL: f
OFFICE COPY