21271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building I'nt'ers Identification P' TNO.
Building Ad,2 IS SID Z7hyV�p._b w� 21271
nera Z one: A A
534 lT/J —D J(,S CITY OF CUPERTINO-BUILDING DIVISION c�/>
Contractor's a Llc.Nm APPLICATION /PERMIT /O_/0 - /v
iiYl/✓f J/9L 5SS BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect glneer. LIc.N.
- ,QQTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: Q �ILLO/V/ jl+u��C PERMRISSUANCE r
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am hemsed under provisions of Chapter 9(commenc. APPLIANCES-RESIDENTIAL JOB DFSCRE'fION
Ingwith Sedion7000)of Mvision3ofthe BudnessmdPmfemionscode,and
Bance is in full effect. PANELS
License Cie. VLk.
Is �l o-tt4 _
Date.-/7_/»_q^ Contractor
AARCHITECI•S DECLARATION 20I-1000AMPS/S `/.
oto O I understand my pe use
plans shall be as public retards. OVER 1000 AMPS I A ( a l SQ.FT.FLOOR AREA 5/`.Q.FI'.
CC r x - l
U Lkereed Professional 9GNS ELTCIRICAL
<y OWNER-BUILDER DECLARATION p r`
7k, 7 IhembyafRrm that l am exempt from the Contractor's License La orthe / SPECIALCIRCUIT/MISC
pp -s following reason.(Section 70iIS,Business Professions Code #
O Z t- T'FMP.MEfL11 OR POLE INST.
P following Mason.
7MIt5,Buri ess and Professions
Code: h,o air
anystm=m intermit,Luuance,also requirestheappeam lora pe tto I
Jml POWFRD CES
.l�
fileCo a signed statement that he V licensed pursuant it the peau-Pettis of the
Ou, Contractor's License Law(Chapter9(commencing with Semon7000)ofpivl- I s
F OS the basis for
thealleedProfnsion. Any orlation V exempt therefrom and S N L _C VALUATION
gy�Sn•-t the bean for the alleged exemption.on. Any violation of Section 70315 by any V A• ^-�
p0�0
applicanthudred permit ects theapplkanttoatlWl penalty o(not morethan O TC FIXTURES / Tot /�7D
ep�
five hundreddollarshepro NEW DENIAL ELECTR ! l/ `-�/
I]> ❑I,as owner of the property,or my employees with wages r [herr sole �'hT• STORIES TYPE CONSTRUCTION
G compensation,will Bu,in the work,and the st Code:ure The
Contractors
ormmeL offered w
� O sale(Sec.7044,Buelna...d Prvtemlons Cade:The Contretlor's Ucense Law
ESR does notapply to an owner of property who builds or improves thereat,andOCGGROUP RIS.UNITS
who does such work himself or through hrsown employees,provided that such
Improvements are not Intended oroffered forsale.If,however,the building or TOTAL:
Improvementbealdwithlnoneyearofcomplel mtheowner-buOderwillhave
t rden olprovingthat he did not build or improve forpurpose ofsale.). QTY, PLUMBING PERMIT FEE p1GODZONE pPN
Lj L as owner of the prep",am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors Llrenso Taw does not apply to an owner of property who
W
ALTER-DRAIN VFM-WATER[EA)
ilds or Improves thereon,and who contracts for such projects with a
con .c or(s)licensed pursuant to the contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_�NIDE �
• WORKMAN COMPENSATION DECLARATION RECEBrI'#
❑1 hereby affirm that I have a¢rtiRrate of consent to self-Insure,orate PER TRAP SCI10pL TAX Y N
certificate ofworkers Compensationlmurance ora certified copy thereo((Sm. REGEPT#
MOD,Lab
1v�Ca0 x{7537 �fO GAS EA.SYSTEM-1 INCA OUTLETS PARK FE _
N_Policy# RECEIPT#
Co�Cny GAS 1i.SYSCQ -0VE4(EA) BUILDING DIV
SIO
NFES
eniOed copy s herebytum
erifletl ropy is(fled with thecity inspection division. GREASE/NDUSML WASE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA Wopr. Date Recei t#
(this section needot b
ne completed tithe permit b(or one hundred dollars
($100ceemifyth ce
( rtify thWATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
at In the performano(the wakfon which this permit is Issued,
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
workers'Compensation Laws of Callfornla
O Z Applicant
Z 0 NOTICETO APPLICANT.If,after makingtids Cert Rlealeof Exemption,you NEW RESIDENTIAL PLMB. SQb7, Date Recei t#
should become subject to the Workers'Compereat ion provisions of the Labor TOTAL-
LU
Code,you must foot hwith comply with such provisions or this permit shall be BUILDING -E i�
LU ] rimmed revoked.
aC CONSTRUCTION LENDING AGENCY SEISMIC FEE t
= Z Thereby aorkmfthat thereisacoostru sseed(Sec.on lending age097,Clforthe pertorm TOTAL: ELECTRIC FEE
O atm of the workforwhlch this permit btxued(Sec.3097,CIv.CJ
LJ lander.Name PLUMBING FEE
LL ~ Lendcr'a Addmas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W l cert By that l have mad this application and pate that the above information
isrorred.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} W relating tobulldingconstruction,and hembyauthomm representatives olthls
F Z city to enter upon the above-mentioned property,for inspection purposes. ALTFRORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
L) agaiuthabllltiea,judgments,co an dexpenseswhichmaylnmywayaccrm AIRIIANDLING UNIT CFO 10,ODOCFM) SUBTOTAL:
Its
insts G gnscqu ofthe gra ntin /t aY Itf -
-� ��-fo-o AIR HANDLING UN7T(OVER IQOOoC.M) CONSTRUCTION TAX
s+ are fApp,I, Contractor Date EXHAUS'PHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or Oundle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined bythe Cupertino MunicipalCode,Chapter9.IZ and the _ Date Recel t#
Health and Safety Coders�Section 25532(a)? HEATING UNIT(OVER 100,000 BTN I
❑Yes u No TOTAL:
Will the applicant or future building oaupant use equipment or devices VFNDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air co,amnants as defined by the Bay Area Air
.
Quality Management DBtdd7 BOILER-COMP(3HP OR 100,DM BTU)
4Yes ❑No
havercadthehazarduusmatcrlabrequlrcmentsunderChapter6.95of BOILGR-COMP(Ova IW'000BTU)
the Calilomb Health&Salety Code,Sections 75505,25533 and 2634. I p�®
understand that if the building does not currently have a tenant,that it N my NEW RESIDENTIAL MECH. SQ.FT sl—
responsibility to notify the occupant of the mquircments which must be met
prior to issuance of a Certificate of Occupancy, l f'j
U 1991)
Owneroraothorized agent pate JN By
TOTAL: a #4r - .-
OFFICE COPY