21566 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 21566
one:
CITY OF CUPERTINO-BUILDING DIVISION 1 t��^
2D Ic.Nex APPLICATION / PERMIT `'2� � _L— W
L SUMDINGELECiRICAL PLUMBING-MECHANICAL CA'fFiGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: ❑ 1:1
❑ _
PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION
I MhSyto lrrothan7OOO)o Divgon3efth.under provWonsofChaonsCormmmen APPLIANCFS.RESIDENfL1L JOB DFSCRNTION
Ingwllh5ect1on700D)of Dlvldon3 ofthe Busineseand ProfeeslamCmde,and
Iwnx ie in fol force and died. PANELS ��
Llmnx Ch® Lk.N_;�d2 �
Dale Contractor [a
ARCHITECT'S DECLARATION 201-IODD AMPS
Oa0 I understand my plaru.hall be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA 6/SQ.Fr.
yqqp�� O
Llmnsod Prderslmul SIGNS ELECTRICAL t
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ 15C
7 �Z Iherebyaffirmthaxe
t I amempt fromthe Contmctmrs LkenxI wfmtlm
oo following reason.Election 70115,Business and Professions Code:Any city or
Pcmntywhkhrequb apermitlomMmct,alter,Improvenn
,Aellsh,orrepair TEMP.METIR ORP
anystm=mpdortolts Wuame,atwrequlre.theapphmnlforsuchpermllto ]�yyER DEVI
file a signed statement that he is licensed pursuant to the provisions of the
3µ Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- NG POOL CVALUATION
SOS slon3ofthe Businro.and PmfenlmroCode)orthat hebexempttherefromand
X the basis for the alleged exemption. Any violation of Section 70)15 by any O TSSWI XTUR
applicant fora permit sublets the applkamto a civil Penalty of not nnrethan
eudmd dollars($500).
as owner of the properly,or my employees with wages as their sole NEWD L ELECTR STORIES TYPE CONSTRUCTION
C7Q corn lIon,-tilde the work andthestiucture Isnot intended or offered for
5 D sale(Sec.7061,Business and Professions Code:The Contractors License Law
NE(1, E does not apply to an owner of property who builds or improves thereon,and OC:.GROUP RFS.UNTfS
who doessuch work hlmelf or through N.own employees,provided that such
Improvements are not Intended or offered for sale,If,however,the building or TAL:
Improvement bsold within oneyearofcompldlorytheowner-bu0derwillhave
lfW-turdenofpmvmgthathe did nm WIIdorlmpmv.f.rp.rp..f.ak.). QTy. PLUMBING PERMIT FEE pWpp wNNE APN
Lf L as owner of the property,am esdmively mntrading with licensed PERMIT ISSUANCE
to construct the project(Sec.7074,Business,and Professions Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN k VENT-WATER(]A)
Wor Improves thereon,and who mntnds far such Plojeds with a FEE SUMMARY
c9atpactor(s)Honed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
Lf I am exempt under Sax, B Is P C for this recon
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
. Owner Date RECIDrI'N
WORKMAN I have a COMPENSATION DECLARATION FIXTURES
TRAP SCHOOLTAX Y N
❑I hereby affirm thaCo I have o Troursate of consent d pythemof ora RECEErT N
3800,Lcertificte bofWorkers'Compensatlonlnsurenmora eertHkd mpythereof(Sec. GAS B.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.) rpr�r✓'7 RECEIPT N
PolkyN /s- / 1 CAS EA.SYSIiM-OVERd(EA)
Coma Thcd. Ajr�' �� BUILDING DIVISION F[G9
�C�rtlRedmpyishVd.it th.dty GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑CedBledropy b filed with ted city InspMlon dlWdon.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2fX1FI. Date Reml t#
Rhbsedlon need net be completed Ifthe permit b forone hundred dollars;
($100)eelessJ WATER HEATER W/VENT/ELGCTR ENERGY FEE' Y 'N
I certifythal in the pedamunca°f the week for which this permit is issued, —
I shag not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensationbwsof Calffomia.Date PAID
licant
,Z Z NOTICE TO APPLICANT:If,ager making this CertHlcate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recel [#
O should become subject to the Worker Compensation provisions of the Labor TOTAL:
V) Code,you moat forthwith comply with such provisions orlhb permit shall be BUILDING
W j deemed revoked.
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyafRrm that there is a renstructlon lending agency for the perform TOTAL: ELECTRIC FEE
M Z arm afthe work forwhich this permit b issued&c.3097,CIv.C.) -
(,) O Lender's Name PLUMBING FEE
LL I— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE t
0 W 'nou lhat a dthbappik tWnanddatethattheaboveinformatian
1 bmrred.lag eetoco plywlth allcityand countymelinaneesand alatelaws, PERMIT ISSUANCE PEES PAID:
} N relating tobullding nstrudion,and Fere u'hodureprexntativesofthb
dtytoen(erupon above-mentbnsdp rtyfminspectionpurpoas. ALTERORADDTOMECH. Recel t#
� ? (We)o t xve, a and harmless the City of Cupedlno Dale
agaWtlbbi e,jud n 'n nxawhkhmrylnanywayaccree AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
ago Wt said sty Inc ca of 1 rating mthls permit.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signsturco(Applicant/Contradmr Date EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ^
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO iWpW BTU) Date Recei f#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Crileru�Section 25532(.)? HEATING UNIT(OVER 100,00)BTT)) TOTAL:
❑Yes fir No
Will the applicant o,f tore building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdous air emusnummm as defined by the Bay Area Air _
• Quality Management District? BOILER-CAMP OHP OR 100,000 BTU) -0—MAID r
4Yea n No
have gad the haza�ou.materbls requirements under Chapter 6.95of BORER.COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,75533 and 75536. 1 f�pTa
understand that if the building don nm currently have a tenant,that It is myNEW RESIDENTIAL MEC-L SQFr. Nf.{j 1 ,* Ion
c
responsibility to notify the oopant of the requlrentrom which must be mel rt
prior to fesua nm of a Certificate of Ocmpanry.
fill
Owneror authorized agent Data ISSUEDB
TOTAL: ,6]d
OFFICE COPY