21355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project rdemlficadonPERMIT NO.
Building ss:
AO 21355
wed 9 ,me: ane: APPLICATION SUBMIT CAL DA IL
CITY OF CUPERTINO-BUILDING DIVISION L G_-Zq,,,�6
Conlarton,Name: LIc.No: APPLICATION / PERMIT 'C
BUILDING-ELECTIUCALPLIIMBING-MECIIAMCAL CATEGORY CONTROL p
rchlteci/Engineer. Lfo.Na:
h $pA IT BUILDING PERMIT INFO
�� GSNu G,Y of ZC CITY • ELECTRIC PERMIT FEE
Add.. A; WW PArd O Td-f PERMBTISSUANCE (�' ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I herebyaffirmthal lamlicensed under provisionsof Chapler9(commne APPLIANCES-RESIDENTIAL �Qm �--� c�J�BDPSCABa]ION
tngwlth5ect1an7000)of DiWalon3ofthe B..t.ss tad ProfeW.,Cadgandmy Ems`
broom is Infullforce and d(ea PANELS
Lou- CD rZ 44L= 3534 1�'Z�j`2yx
Dated Contractor Yar UP TO 2DOAMPS
201-1000 AMPS
ARCHITECTS DECLARATION
OreO !understand my pilo shall be used as publicremrda OVER 1000 AMI5 SQ.FT.FLOOR AREA S/SQ.FI'.
bG Ltareed Professional - SIGNS ELECTRICAL
<< OWNER-BUILDER DECLARATION SPECULCIRCUIT/MLSC
I-, q !hereby alarm that am exempt from the Contractors License law forthe
09- lollowleg reason.(Section 7031.5,Btai...nd Professions Code:Any city or TpAlp METER OR POLE!NST.
muntywhlchrequi apermlttommtmct,Otenlmpmwdemolfsh,orrepair
a anystructure Inform its issuance,alsorequirestheappBant for such permit to POWER DEVICES
U Rle a signed statement that he is licensed pursuant to the provisions of the
ta Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
VALUATION
slan3of the Business and['rafe®ioroCode)orthat hebexempt there(romand
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS�SWTTCHESHXfURES _ a
applicant fora permit subj ctsthe applicant to a civil penalty of net more than
five hundred dollars(&500). NEW RESIDENTIAL.ELECTR
❑1,as owner of the property,or my employees with wages as their sola SQ' STORIES TYPE CONSTRUCTION
tcompensation,wilidothe warondthestructure is net intended or offered for
5 O sale(Sec.7044,Bu.Imsa and Pmfessimu Code:The Comrsam,s Llmtue Law
$ does nut apply to an owner of property who builds or improve,thereon.and /0
who doessuchwerk hime4forthrough hleawnemployees,provided that such ` OCC.GROUT' RES.UNITS
Improvements are not Intended om(fered forsee.If,however,thebullding or TOTAL: l
Improvementlssold withinowyearofcomplemgtheowner-bu0derwRl have
tl�jkurdsnof provingthat he did not build orlmpmrpeonb.. 07Y, MI
ve forpuoef ) PLUMBING PERT FEE FLOOD APN
LJ
[or owner of the property,am exclusively Business
and contractingwithlicensed PFRMITISSUANCE
contractors to co Liven thew doe norScc.apply
Business and Professions property
Cade;
The Coor Impr'e as th a law don Mat apply to an owner d property who
builds t r Improves thereua and who mntrce. for such ptofem with a ALTER-DRAIN&VENT-WATER(EA)
c L-II ar exempt
under ant to the Cantnctofe License Law. FEE SUMMARYDE FEES L I am exempt under Sec B A P C for this rcmn BACK FLOW PROTECT.DEVICE OUTSI
Owner Date DRAINS.FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
• — RECF]PTN
WORKMAN COMPENSATION DECLARATION
7RAP� r SCHOOL TAX Y_ N
❑I hereby orker that 1 have a Insurance
of consent m self-Insure,ora RECFIII'I'N
catif3800,ab of Warkers'Compemation lruurance oracertl(kd copy[hereo((Sec. gg.pA.SYSI;p.N-1 INC40UAxR-m PARK FRE Y_ N
3800,lab CJ
Policy N - - RECEIPT N
^W.SYSTFAI-0 4(EA)�
Com any BUILDING DIVISION FEES
Certified copy Is hereby furnished, CR Rp DusHc B R PLANCHECK FEE
�CertNed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' E7RAP "- PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MOF!'. Date Revel tN
(Thlsseedoo need not be completed lithe permit isfor one hundred dollar
(3100)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance ofthe work for which this Permit is issued,
1 atoll not employ any person in any manner n as to become subject to the WATER SYSTEM/TREATING
Worken'ComNnsabon Lasveof California. Date PAID
O Applicant Date Recei tit
2ng NEW RESIDENTIAL PLMB._SOFT.
Z O NOTICbecomeETO APPLICANT:If,corkersfter cam a CationCattfprocate is Exemption,you
� should become subject to the Workers Compensation provlaloru ofthe Lobar TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be_ BUILDING FEE
W > domed revoked. .
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL z herebyaffiro"hat which
taamrutnctssued dlc. a 7,cyfonlhe perform- - - ELECTRIC FEE
0 Z anrao(theworklar whkhthb permit Is;leered(Sec.3097,C1v.C.) ,
TOTAL:
'
02 lenaera N,me PLUMBING FEE
LL,h lender's Add mss OTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Iadifyth.t I have read thusppllcatloMand statethattheabove Information
O W
1 bmrrect.lagreeto comply with all cityand ecuntyardlnanms and Yate laws PFRMITISSUANCE FEES PAID:
>. W relating rebuilding amstruciion,and Mreby authodu representatives ofthis
F U) city to eeterupon the a bo reentimird property for Inspection purposes. ALTERORADDTOMECH. Date Ri ted
(We)agree to save,indemnify an d keep harmless the City of Cupertino eceP
V against liabilities,pdgmenta,Carteaud expenses which may In anywayaarue AIR HANDLING UNIT CFO 10,ODO CFM) SUBTOTAL:
against said City in mnuquence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Sigriamreof Appilan ontracim, - Date EXHAUST HOOD(W/DIKT)
HA RDOUSMATERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hasardous HEATING UNIT(TO 100,000 BTU) Date Recei of
material as defined by the Cupertino MuNdpal Cade,Chapter 9.12,and the
Health and Safety Code Section 2S532W2 HEATING UNIT(OVER 100,000 BTU) TOTAL: L
❑.Yn In No
Will the applicant or Future building ocapant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit ham rdous air mntaMoants as defined by the Bay Area Air
Qua Ity Management Dlatdtt7 BOILER-CAMP OHP OR 100,000 BTU)
Ye, No4hvadtheham!❑us m
aterialsmictmmensunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the ailrn
Health 4 Safety Code,Sections 75505,25533 and 25534.I rJa r
understand that if the building does not mnren0y have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT �-
respornibllity to notify the occupant of the requlremenle which at be mer
prior to issuance of a Certificate of Occupancy. 4 7��
Owner or authodud agent - Date TOTAL: ISSUEDBY As[11,44v—
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OFFICE COPY