21514 APPLICANT TO FILL IN INFORMATION WITHIN RED.LINES — USE BALL POINT PEN ONLY
Baildln Project Identification P' TNO.
BulWing Address: - 21514
a_* �[
ners ams:
qel,, ane CITY OF CUPERTINO-BUILDING DIVISION
x" If tnctar. Lie.Nm APPLICATION / PERMIT
r � BUILDMGELECTRICAL-PELECTRICALCATEGORY CONTROL N
` ArtM1ifM/Engineer. Lk.No:
BUILDING PERMIT INFO
•�": QTY ELECTRIC PERMIT FEE
Adtlress: OPERMITISSUANCII �t OP 1:1 '[l) ❑ ❑
LICENSED CONTRACTOR'S DECLARATION US,J
I hereby afflrmthat l am licensed under provisions of Chapter9(commenc. APPLIANCES-RESIDENTIAL LOB DESCRIPTIONIngwlthSeetion7000)ofDiW.lon3oftheBusimasandPmfessionsCode,and my -
It..la In full force and effect. PANELS
License Chs connector
Date Contractor
ARCHITECTS DECLARATION 201-IOOOAMPS
nt0 Z I understand my plana shall be used as public record. OVFR]000 AMPS SQ.FT.FLOOR AREA SM.Fr.
O
Licensed Professional SIGNSELECTRICAL
G6 OWNER-BUILDER DECLARATION SPFCIALCIRCNT/M15C
2 y, 6 I hereby affirm that I am exempt from the Contractors License Law for the
pp following...(5ectlon 7Q81S,Busine.cand Profesbns Code:An ef or
O Z i. y ty TEMP.METER OR POLE INS!.
P� cauntycture requltesa inmaneaborequirmtheapmvgdertnWh,armitto
any.wctaretatementahauamga remsed rersuant to the pro such ions of to POWER DEVICES
O 0. Ole a signed @dement that he t rcensed e pursuant it the provisions of the
��((�� Contractors LlcenaeLaw(Chap[er9(commencing with Section 7000)of Divi- SW8.4.ONG POOL ELECTRIC VALUATION
1 sloes 3 ofthe Business and PmfeslomCode)orthat heh exempt therefromand '1
o.•fid] the basis for the alleged exemption. Any violation of SMtan 70315 by any OUTLETSSWITCHESFI%Il1RE5 (�V
appEant for a permit subjemtheappikant to a civil penalty of not more Han t
flv�undred dollen($5(10). es NEW RESIDENTIAL ELECTR SQFr. STORIES TYPECONSTRUCTION
�n I,as owner of the property,or my employewith wages as their sok
mmpensation,will dothe work and thestructure is not Intended or offered for
Os1e(Sec.7044,Bualneaaand Professions Code:The Contractors License Law
does not apply to an owner of property who Wilda or Improves thereon,and OCC.CROUP RE&UNTES
whodansuchworkhl lfe threughhlsownemployees,providedthatmch
improvementsare not intended oroffered!orale.If,however,thebuildingor TOTAL; 0
Improvement b sold within oneyearofcompletiog thewvner-bullderwW have
tf(�rden of proving that la did not build or Improve for purpose ofsakJ. CITY. PLUMBING PERMIT FE FLOOD ZONE APN
LJ 1,as owner of the properly,am exclusively contracting with licensed
contractor to conalruct the project(Soo 7044.Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN ANENT-WATER(EA)
Wilds or improves thereon, and who contrafee such pzpjem with. FEE SUMMARY
�lactor(s)lkerued pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sm. B A P C for this reawn
DRAINS FLOOR ROOF,ARRA, SANITARY Y_ N_
Owner Date RECEIPT R
tf� WORKMANCOMPENSATIONDECLARATION FIXTURES I'F3t TRAP SCHOOLTAX Y N
1 L.J a Ly affirm that I have a artifiate of consent to self-Insure,or RFLEB'r N
cart Laurance ore certified copy tM1ertof(See.
3800,Lab CJ GA&FA.SYSIRM-II .4 OUILPARK FEE Y N
• ''� -� PolicyM 11 GAS.FA.SYSI7.1/-0V (EA) RECEIPT#
cont any BUILDING DIVISION FEES
cc
copy is hereby famished. GREASE/INOUSIRL WA R PLANGFIECK FEE
E3CerlRted copy h filed with the city inspection division.
CERTIFICATE OF IXEMPrION FROM WORKERS' GREASE TRAP V
PAID
COMPENSATION INSURANCE SEWER-gAM.f.ARY-b10YJ
p0E-T• Date Recei ted
Dhieeection need na M completedlithe peran t h forom hundred dollar
(9t W)Or lead WATER HEATER W/VENT/F7.ECTR ENERGY FEE Y N
I mrify that In the performanceof the work forwhich this permit Is kaed,
1 shall not employ Any
person In any manner an
as rb'ect to the WATER SYSTEM/TREATING
Workers Co nsatlorL ors Ilromh.Date -L - PAID
licant
Z Z NOl]CE TO APPLICANT:B,after rtukln thk Certifiateof Emroptian,yot NEW RESIDENTIAL PLMB' SQ'FT. Date Recei t#
should become subject to the Worker'Compemation provisions of the Labor TOTAL:
CN Code,you neat forthwith comply with such provisions or this permit shall be BUILDING
W j deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafflrm that there h a construction lendingagency for the perform ELECTRIC PEE p
0
Z ante oftheworkforwhichthhpermithlaaved(Se 3097,Civ.C.) TOTAL: i•
U iq
O Lender.Name PLUMBING FEE
LL F L.endera Addre.. CITY. MECHANICAL PERMIT FEE MECHANICAL FEE
O isco1mrtlfythatl have mad thhappliatlonand statethattheabovelnformation
W rrect.I agmcm complywlth all cityand county ordinances and Gate laws PERMIT ISSUANCE FEES PAID:
} relating tomilding construction,and hereby authorise representatives ofthis .
N city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
? (We)agree to ave,Indemnify an d keep harmless the City of Cu portion Date Receipt#
V
against liabilities,judgments,metsand expenses which may in any way accrue AIR HANDLING UNIT DO 10,000 CFM) - SUBTOTAL:
��ag.ipa�said City m once of the granting of this permit. AIR HANDLING UNIT(OVER 10,000CFT1) CONSTRUCTION TAX
2bctor /Z—#--?O D CONSTRUCTION TAX PAID:
IgnaNreo(AppRant/Contractor Dale EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le harardous HEATING UNIT(TO 100,000 BTU) Date Recei tit
material as defined by the Cu Penton Municipal Code,Chapter 9.12,and the
Health and Safety Cod e, 25532(a)t HFA71NG UNIT(OVER 100,000 BILA TOTAL:
❑Yes No
Will the applicant or future building occupant use equipment or devious VENTILATION FAN(SINGLE RESIO) Igcly/,'ta[.FDATE
which emit hannious air coma mina nus as dell ned by the Bay Area Air �6a�-
Quality Management D�ish�3� BOILER-COMP Of OR 10,!%10 BTU)
❑Yea �N�o TL[[''//as Q�Ms�f]
a !t 1 I have read the baax snot us materials requirements under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU) Fi fa,y �"rY
}- the Califomh Health A Safety Code,Beef..25505,25533 and 25534.1
understand that lfthebuilding does not currently haveat....L that it is my NEW RESIDENTIAL MECO. SQFr.
/ responsibility to notify the occupant of the requirements which moat be mete
pri suanof Cc t2deoTf�O+mpaoqO.
Oc
wnerorauthorleed
agent Date - TOTAL: ISSOEDBY: 4,
OFFICE COPY