21798zZ
'd.
In�fl,
e -
9F3
.55<
i
•E;m�
x
r�$
•
I— N
cc 5
LU G
CL
7 O
U_
LLh
OW
F (A
Z
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building 1'miect Identification
Building Address:
PIJNUT NO.
(�3S
21798
_
wncrsone
APPLICA nON SUBMii LAE=
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BURR)NGELEC'RUCAI.MUMBING-MECHAMCAL
Cantu' me: Lit Ny�
�7 ,R
CATEGORY
CONTROL
Archuert/Engrnaer. I Lk. No:
...
QTY :` y^ ELEC[RiC PERIvITC,`;`,_' '..FEE -
BUILDING PERMIT INFO
Address
PQthBTISSUANCE �2 (,'�
O ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
APPLIANC6RF_SIDENTIAL
JOB DESCI2B'170N
PANELS
oInnlhelfamlkms0ftheBrprovand Prtessumer9(mmmmc
Ine.is 1. failto. of Divfict. (theBuNnnaadProfessions Cede,and my
Laveie InfuBforteand n.# f .� I,f
LlanseC s — bLic♦ .3 %
{^
Fit
Date Contractor (.EL'
ON
Am shall be
1 understand my plan shall be used a public reooma
Public
OVER00AMPS
OVER IOW AMPSSQ.
FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCBtCU[T/M15C
OWNER -BUILDER DECLARATION.
I herebyefflrmlWt 14m exempt from the Contractors License law f¢ the
TEMP METER OR POLE INST.
zor-n
following mason. (Section 7015, Bushes and Professions Code: Any city, or
cou n ty wh ich requires a pemdt to cpm muct, alter, Improve, demolish, or repair
any strurturt prior to its bussme,abe requires the applicant far such permit to
file a signed statement that he Is lloenaed pursuant to the provisions of the
POWER UE1gCFS
9KMAM(NG POOL ELECTRIC
OUT(.EISSWITCFIESflXTURES
Contractors License law (Chapter 9 (comnte.ang with Section 7000).f Divi-
eicn 3 of the Business and Peafessiove Code).,that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7015 by any
appBant lora permit subjects the applicant too civil penalty of nct more than
VALUATION
five hundred dollars ($W.
O1, u ower of the pmpesty, or my employees with wages a theirrole
NEW RESIDENTIAL ELEC71( SQ}7.
STORIES
TYPECONSTRUCTION
mmpenaabon,will dothework andthestmcture Is not intended or offered for
ale ($erg 7064, Bualnaa and Profeslons Codc The Contactals LI¢ve Taw
go
docs n¢ apply to an caner of property who builds or Improves theeatn, and
whodoessuch workhimseRw
arthrgh Msawnemployma, previdedthatsuch
.GROUT'
RES. UNITS
Improvements are not intended proffered formic. If, however,thebullding or
TOTAL
improvement lawldwithinorayearo(completion,the owner-builderwill have
t rden of proving that he did not build or Improve for purpose orale.).
LJ L a owner of the property, am exclusively mntncta g with licensed
conmcioa to mnstroci the project (Sec 7M6, Bailees and ProfessionsCode:
QI`y: `%''•, PLUMBING PERMIT' ''"FEE.'
FLOOD TONE
APN
pin. ISSUANCE
The Comeacto/a License Law does net apply to e, owner of property who
bunds or Improves thereon, and who mntnrts f¢ such p(akcts with a
to darts) licensed pursuant to the Contractors Limns Law.
L,f I am exempt under See B 3s P C for this reason
ALTFR•DRAIN& VENT- WATER(EA)
.I FEE SUMMARY-.:,
BACKFLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
REC= 0
Owner Date
WORKMANCOMPENSATIONDECURATION
❑f hereby affirm that I have a certificate of consent to seII-Insure, or a
art(fiateofWorkn
e' Compensation lnacar
unime e artBled copythereof(See.
380, Lab CJ
Policy#_ Pe, 990r.
FIXTURES PER TRAP
SCHOOL TAX Y N
RECF]PI «
GAC EA. BYSTEtd-]1NUOVILEfS
PARK IEE Y N
RECEIPTN
-C
Com�+rev �• J Ur
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
I IcertNed copy is hembymmished.
art V ed copy Is coed with the a ty inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(Thisseadon need me he completed if the permit isfo ons hundred dollars
SEW FR-SANRARY-SIORMU XIOFI
Date RCCCI t#
WATER I-DwTFxw/vENT/o.EcrR
ENERGY FEE Y N
PAID
(5100)arles.)
I certify that N the performance of the work for which this permit is Issued,
1 shall me employ any person In any manner so as to became abject to the
Woken' Compevsic n Taws of California. Data
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should became subject to the Workers' Compensation provisiom of the Labor
Date Recei t#
NEW RESIDENTIAL PIMB. 50F7.
TOTAL:
Cade, you most forthwith comply with such provisions orthl, permit shall he
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hembyafflrmthat then Is a commuction Lending agency for the perform,
ansa of the work for whkh this permit is blued Bee 3097, CIv.C.)
lander'c Name
Leader.Addresa
Tout:
- -
ELECTRIC FEE
L
PLUMBING FEE
QTY. '';,• 'MECHANICAL:PERMIT; ..'FEE.:,
MECHANICAL FEE
I¢difythatlhavereadthbapphmtionandpatethattheabmeinfommion
bcorrect. l a gree to comply with all city and countyordinanasand statelaws
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize repmentativn alibis
citytoenlerupon the abnwcnxxrtord property for inspection purposes.
gra to ave, indemN n d km armless the Clty of Cupertino
ALTER OR ADD TO MECH.
Date Rete) t#
AIR HANDLING UNIT CTO 10,000 CFM)
SUBTOTAL'
against' blllties,judgmenb, sand ex n ewhic yin yway...
against Id C`tylncoe of the a effort t.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
S a vm.l ApplIart/Contractor Dae
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL DISCLOSURE
HEATING UNIT (TO 10,00 BTU)
HEATING UNIT (OVER 10,000 BT1J)
Date Retei t#
TOTAL:'
Will theapplant 0, forum building occvpametore car handle hazardous
material as defined by the CaperMunicipal Code, Chapter 9.17, and the
Health and Safety Code Section 755314)1
❑ Yes
WOIthe SppBant orfuture M No
building occupant use equipram or devices
0�
VENTILATION FAN (SINGLE RESID)
i,
ISSUA*,Nd. DATE
which emit havrdous air conlaminanta as de0vd by the Bay Area Air
Quality Management District?
Yes nn No
t
�`iN / }
BOILER -COMP ORP OR IDL000 BTI))
BOILER-COMP(OVER 10,000 BTUI
have read the havr�ous materials requiremeebunder Chapter6.9i of
the California Health & SafetyCode, Sections 25505, 25S33 and 15536. 1
understand that lithe buildingn donot currently have a tenant, that itis my
responsibility to orally the occupant of the empircmema which must he rant
Fs�sv��ts�
p/yglYiaYli
__....---
NEW RESIDENTIAL MECH. SQ.FT.
prior toissuance of a Certificate of Occupancy.
Owner or authorized agent Date
TOTAL.'
OFFICE COPY