21400 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO,
BuildingAddress: C L 21400
Mfg ante: Ont:
-APMTCKTrM SUBMITTALA
SIO✓t CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Llc.No, r APPLICATION / PERMIT AiJ✓ G /9�0
raj BUILDINGELECTRICAL41UMBINGMECHAhTCAL CATEGORY CONTROL#
ArtM1 iM/Engineer. - Lk.No;.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..
PERMITISSUANCE ❑ ❑ ❑
91
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapler9(commenc APPLIANCESRESIDEMIAL JOB DESCRIPTION
SeRion7OOD)of DiA.lon3ofthe Busin and ProfesslonsCode,and my
Iianulstnfu1lforceandef1M. ' PANELS
License C/a6- O G-,ca LION - - o� G
Dated Contractor 6/, z'(nJ •. Up TO 2DO A
ARCHITECTS DECLARATION 21114000 AMPS
�❑❑++a0 O I understand my plans shaB be used M public rxrords. OVER l O00 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ked 0) Licsed v
enPmfmiuf SIGNS ELECTRICAL
GX, OWNER-BUILDER DECLARATION SPEC NT/M]SC
79r Ihereby affirm thatl am exempt from the Contractor's License Law for the
O G i. following reason.(Section 90315,Business and Prefeselons Code:Any city or q (;M R E I '
r54 cm my which requlresa permit to constmer,alter,Improve,demolish,orrepair
YYras anysima mpciortoibtssuanee,aLsorequimtheappRantforsuchpemdtto IO ,DM
file a signed statement that he,is licensed pursuant to the provisions of the
03°0� Contractors License Law(Chapter 9(comnancing with Section 9000)of Dist- G LELE
alon3 ofthe Business and Professions Code orthat he b exempt therefromand VALUATION
S°S the basis for the alleged exemption. Any violation of Section 9031.5 by any rJ
applicant fora permit subjects the applicant to a civil penalty d net morethan GUILE HES applicant
GsJ�
five hundred delta.(5500).
❑I,as owner of the property,or my employees with wages as their sole NEW E TR--SQ'FT. STORIES 1YI CONSTRUCTION
G < mmpcnsation,wllldothework,andthestructurebnmintended or offered for 1
O ale(Sec.9004,Business and Professions Code:The Contractors Licersse Law
does not apply to an owner of property who Wilds or improves thermr4 and -
"' who doessuchwork him9elforthrough hisownemployees,provided that such OCC.GROUP RIS.IIlVTfS
improvements are not intended oroffered for sale.If,however thebuildineg or TOTAL:
improvement Lssold withinoneyearofcompldRo theowner-builderwill have
thX-hurden of pmvlog that he did nm build or improve for purpose ofsale.). Q. PL BI G E FEE FLOODZOh'E APN
LJ C as owner of the property,am exclusively contracting with licensed PERMITI C
contractorsm constivR the pmjM(Sec,9014,Businm and Professions Cede:
The Contractor's License Law does not apply to an owner of property who �,�ORA &VENT W ,CFR(EA)
Wilds or Improves thereoq.m
d who contracts for such p,prets with a
,p�TaRo(s)licensed pursuant to the Contactors License Law. BACK FLOW T.D E FEE SUMMARY
1_J I am exempt under Sec B h P C for this reason
Owner Date DRAINS-FIOORR F,AREA,COND. SANITARY RFOEIFN
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certifiate of consent to self-insure,or a FIXTURES PER TRAP SCHOOL TAX Y N
ceni(irate of Worken'Comperaation Insurance w a certified copy thenrof(Sec, RECEIPT N
38M Lab CO GAS EA.SYSTEM-I WCAOUTLETS PARK FEE Y N
1'.11;;# BE =p
Com n <T-p�r GAS EA.SYSTEM-OVER 4(FA) BUILUINC DI VISION FEES
2C(fertlhd copy is herebytumishd. GREASE/WDUSHIL WASTE INTERCEPTOR PLANCI-IGCK FEE
ertifid copy V(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(1'1hissectionneed net becompletd tithe permit Lsforone,hundred dollars SEWER-SANITARY-STORM EA.2DUFF. Date Reeei tlf
(4100)orlmJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I am lsss.at In the performance o(the week for which this permit is owed, _
I shalt not employ any peon In any manner so as to become subject to the
Workers'Compcnation Lawsof Ca fomis. Date /I-A-SO WATER SYSTEM/TREATING PAID
Applicant�pdf/ani Y/Srl1k'71_
Z 0 NOTICETO Tr u,.—makingthb CertBtateof Exemption,you NEW RESIDENTIAL PLMB. SQFF. Date Recei til
should became eubjM to the Worken'Compensation provisions of the Labor TOTAL:
WN Code,you must forthwith comply with such pm,laions or this permitahall be
> decreed revoked. BUILDING FE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm twd
that there is a coraction loingagency for the perform-
O ance of the work for which this permit b ELECTRIC FEE
issued(Sec.3097,Civ.C.) TOTAL:
V Lender.Name PLUMBING FEE
LL F cnder'sAddress QTY. MECHANICAL PERMIT FEE
O W IuAtfythat l have read this application andmatethatthe above Information MECHANICAL PGE
1 correct.Idgreete,complywith all city and county ordinances and pate laws PFRMITISSUANCE /.1!. O FEES PAID:
- W relating to building construction,and herebyauthoriae representatives ofthls
F- Z etyto enterupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
V - (We)agree to ave,Indemnify an d keep harmless the City of Cupertino Date ReeeiPtM
against lhbBltice,jod ms,coos and expenses which may in any way accrue AIR HANDLING UNIT CFO 10,000 CEM)
ago Wtald to sequence oftFe granting otthis Permit. SUBTOTAL-
MR HANDGNG UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Slgwiur of Applicant/Contractor Date ! EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hacardous HEATING UNIT(f0100,000 BTU) �,QC:i�
material as defined by the Cupertino Municipal Cde,Chapter 933 and the _ Date ReceiplN
I te❑ehll Yard SalRy Cads,Sect 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL•
Will the applicant, suns building occupant use equiprrent or devices VENTILATION FAN(SINGLE RESID) 1$$UAIF G, IIJ
which emit haranlous air contamlnsnts as defind by the Bay Area Air l
Quality Management District? BOILER-COMP OFI'OR 100,000 BTU)
Yca lgNo
have read the haza us madt , d,rsq.1mments u.der Cha pter 6.95 of BOILER-COMP(OVER 100,000 BTU)
Nov01/ !ls '1
.the Glllomla Health&Safety Cede,SMlons 2550.5,25533 and 2SSM. I VV
understand that if the building does not currently have.tenant,that it B my NEWRESIDFNTTALMECH. SQ.FT.
r.ponsibilityto.coif trtlf= aOcruperequlrereente which must be met e
priortolssu ofrtilicate of Ocmpanry.
e
vwner>Tra thonu agcy/ Date Y
TOTAL: 30 ISSUEDBY: .IGC A/vJ
OFFICE COPY