21606 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I I .PERMIT NO.
Butidlag Address:_ t0670 wt. 21606
one; APvLICAnONSUuMrrAr FA CITY OF CUPERTINO-BUILDING DIVISION
c°ntr ale 5 �� Lie.No; APPLICATION I PERMIT
I BUILDING-ELECnUCAL PLLJMBING-MECHAMCAL CATEGORY CONTROL N
- Architeet/Enginear. - Lie Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
CONTRACTOR'SLICENSED DECLARATION
PERMITI
SSUANCE
IMr lamdunder paCnenc AIIANCESRESIDENML ❑ ]❑pg DCR6f10N
ingwith Scction7000)osiom3 oftheBusiessandPro(nssionsCode,ad my
luces.le ih !Wsod effect. PANELS
License Cess= �_ lc.a
Dale Contacor 6, rW
❑
'
ARCHITECT'S DECLARATION 301-1000 AMPS
QZ I understand my plana shall be used n public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional - SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
Z,�4y p 5 ECALCRCNT/MSC
`J, Ihereb a(Brm thatlam.seem from the Conenslola License Law for the
following reason.(Section 7031.5,Business and Profession.Code:Any city or
Ff'u, =ntywhkhmqu4 apermitwmrutroalterimpmve,de=lbh,orrepalr TEMP METER OR!'OLE]NST. '
§§§y�y - anystmu mpriwtoib Wuance,a3 mrequl theapplimntfmsuchpert tto POWER DEVICES
C r.5 - file a signed statement that he is limned pursuant to the provisiom of the
SOle Contractor'.Llcene law K:hapter9(commencing with Section 70W)of Dist. VALUATION
OS don 3 of the Business and Profession Code)or that he b exempt therefromand SWIMMING R70L'ELE
<� the basis for the alleged exemption. Anyviolatlonof Section7031.5byany OUTLETSSW[TCHFSFI
applicant for a permit subject ithe applicant to a civil penalty of not more than
Eye hundred dollars($500). NEWR ENTIAL EL .FI. STORIES TYPE CONSTRUCTION
�n F11,as owner of the property,or my employees with wages as their sok
t rompensatlon,wBl dothe work andlheevucture h not Intended or offered for
5 0 sale(See 70K Bue1"e..and Profession Code:The Commodore Limns Law
[/j $ docs not apply to an owner of property who build,or Improves thereon,and OCG GROUP RFS.(INKS
whodoeeeuchworkhimeelforthrough hisown employee,,provided that such
Improvements are not Intended°roffered for sale.!(,however,the bullding or TOTAL: '
improvememissold wlthinoneyearofcompletion,the owner-bullderwill have
tl�urdeno(proving that M did not build or improve for purpox.f.,.. QTy, PL TNG PERMIT FEE LJ L as owner of the m FLOOD TONE APN
p perry,am exdnlvely oantracting whh Ikans,d PERMIT E
contractors to controct the project(Sec 7094 Business and Profession Code: -
TEe Contractors License Law dm not apply to an owner of property who ALTER-DRAIN h VENT-WATER(EA)
Wilds or lmro
pnm thereon, and who contracts for such p(ojects with
�+ctm(s)licensed pursuant to the Contnctoes License Law. IFEE SUMMARY
LJ I am'exempt under See B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date
DRAMS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT X
WORKMAN COMPENSATION DECLARATION SCHOOLE'AX Y N_
01 hereby affirm cese6 rcF0(TURES PER TRAP that I have a rtificate of consent to -Inw
,or RECEIPT N
3800,l
cen0Labb C.I ao(Worken'Compenatlonlvunna an certified mpymereof(Sac. GAS EA.SYSTEM-I ING90UTLETS PARK FEE R N
Polity M RFCFR'I M
GAS FA.SYSTEM-OVER4(FA)
Com any BUILDING DI VISION FEES
�Cedi ropy b hercbyththe city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
]fled ropy V(lied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID '
COMPENSATION INSURANCE / SLIVER-SANITARY-STORM EA.1'OOFf. Date ReceI t((
(This section need not becompleted If the perndt(a for on hundred dollars a
($10D)Iordify that
WATER HEATER W/VENT/m ECTR ENERGY FEE Y N
Icertify[halotheper(o rain nyt nnerwmtohthispermitbkothe
I ore not employ any person In any manner so as to become subject to the WATFA 5Y5-1'EM/TREATING
Workers Compensation Lowe of California. Date PAID '
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Rece1 tic
Z O NOTICETO APPLICANT:If,after maktngthis Certificate of Exempiceyou
should become subkct to the Workers''C°mpenation provbionaTthe Labor - TOTAL:
N Code,you at forthwith comply with such provision orthis permit shall be 13UI G•FEE -
WD deemed revoked.
n F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z mIherebyaffirmntr
that there is a coaction kndlngagency(°rthe perform- ELECTRIC FEE
7 anoftheworkforwhlchthb permit 9 Issued(5ce.3097,CIv.C.) TOTAL:
(.) 2 Iandce.Name PLUMBING FEE
FLED—
LL H Lendcre Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Indifythatlhavereadthisapplicationandstatethattheabovelnformation
a Iscorrm.I agreeto complywith allcity and county ordinances and Axle laws PERMIT ISSUANCE FEES PAID:
} (O relating to building conauctlon,and herebyaurhodze represamtsolves.fthi,
F city to enter upon the above-mentioned property for inspected purposes. ALTERORADDTOMECH. -
Z Date • Recei fp
(We)a save,Indemnify and keep harmicss the City of Cupertino P
agalnt iii( Jir ,mrteand expenses whichmayinanywayarrue AIR HANDLING UNIT CIO 10,0110 CFM) SUBTOTAL:
,gal aaidC In n ence oiled gofthiepennit.
/ ,?o AIR HANDLING UNIT(OVER t0,000CFMI CONSTRUCTION TAX
gna of Appllont/Contactor - Data 7 V EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATE LS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTI])
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the Date, Recei IN
Health and Safety Code Section25532(a)? HEATING UNIT(OVER 100,"BTU) L: sov
❑Yee No PIMMI
Willthea pplicant Mrs,building occupant use equipment ordmices VENTILATION FAN(SINGLE RESID) (ISSUANCE DATE
which emit harardous air containments as defined by the Bay Area Air ( �s Ys y
Ir Quality Management District? BORER-COMP OHI'OR t 00,00D BM
i 19.9aYes ❑No
have read the hazardous materials requlrernentsunder Chapterti.95 of BORER-COMP(OVER 100,000 BTU) /N� r
�r the Callfomia Health k Safety Code,Sect ion 75505,25533 and 25539.1 iy
t understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI.
responsibility to notify the oc spa nt of the requirements which most be crit
prior to Laos ace Of a Certificate of Occupy my.
Owner or authorlud agent Data ISSUED BY'
TOTAL:
OFFICE COPY