21936 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
Building Address: 21936
e.L•G-T c• J1ui7Vs0v 2.57-3,6 "'f CITYOFCUPERTINO-BUILDING DIVISION
Contuluor.Name: LIc.No, APPLICATION / PERMIT 1 ( I
Architect/Fsglneer. Lk.No: BUILDINGELECRECALPLUMBING-MKHAMCAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I LL�I PLUME MUCH
❑LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE El El
I herSectio 7000).m,that lam Bce3.fthunder Busir vLslonsoffesk tsr9de,and c- APrL[ANCESRESIDEN77AL JOB DESCRIPTION
Ii.n.i in full
force
eafd dslon3ottheBusinessand Prolesaione Code,and my
Breese bins—forceanderre#_. PANELS r7� 4,/ 9
License Class Lie# F/�3 /(P _
Date Contractor +I
ARCHITECTS DECLARATION 201-1000AMPS
I understand my plans shall M used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.
k I=j Licensed Professional SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SIPECIALCIRCU[T/MISC
1.. ; Iherebyaflrmthat lamexempt fromthe Contractor'sLlcense lawfwthe
9— following reason.(Se tion 70315,Business and Professions Code:Any city or
O G t- TEMP.MEDR OR POLE INSE.
Cg cauntywhlchrequ4 apert ttomesusct,alter,impmvgdennlbh,orrepair
.o any strutum priorto Its Lswance,aiso requlrestheapplicantfor such permit to
file a signed tatement that he is licensed pursuant to the provisions of the POWER DEVICES
u,
Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi-
SWIMMING POOL ELECTRIC
the basis fo theaesaand Profession. Any)ortheon of exempt therefrom and VALUATION
•..cit the basis for the allegM exemption. Any violation of Section 7031.5 by any
pplicant for a permitaubjects the applicant to a civil penalty of not rtnre than OUTLETS-SWETCHPSHXTURES
a f dollarhe . NEW RESIDEMIAL ELECIR N'SIRUCTION
p5 TYIPECO
I,assowner of the property,or my employees with wages a their sole
� ¢ satlon,wlll dotM work and Nestruture b not intendedor offered for
❑ sale(Sec.7064,Business and Professions Code:The Contractors License Law
5$ does not apply to m owner d property who Wilds or improve thereon,and ROUP RFS.LENTIS
who doessuchwork himseUmrthrwgh Msown employees,provided that such OCC,C
improvements are not Intended oroffered forsale.K however thebullding or TOTAL:
improvement bsold within oneyearofcompltion,the owner-builderwill have
t rden of proving that he did not build or Improve for purpose ofeak.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
4 as owner of the Property,am exclusively ontractI g with licensed PERMIT ISSUANCE -D 0
contractors to construct the pmjet(Sm.7064,Businev and Professlona Code:
The Contractor's License Law does not apply to an owner a pmperty who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such poojets with a
tor(s)Bmeaedpunuanttothe Convctors LicenseLaw. BACK FLOW PROTEGE.DEVICE FEE SUMMARY
U I am exe der S r B& P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEQeT#
WORKMAN COMPLNSATION DECLAR 10
❑I hereby affirm that I have a certificate of consent m self-Insure,ora FIXTURES PER TRAP (�0 SCHOOL TAX Y N
comfinds of Workeri Compenaatlon Inumanmora certified copy thereof(Sec RICEITT M
3800,Lab C.) GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
- roll # —
Com any GAS EA.SYSET MOVER 6(EA) RECEIPT
�Ceti0ed copy b hereby fut,lahed. BUILDING DIVISION FEES
�Certified copy b filed with the city inapection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA MOPE, Date Recti t#
Q).r haplon need est he completed Bthe permit bfor one hundred dollar
(St00emlyts.) wATEA NERGY FEE Y N
. Icertlythat in the performance of the work forwNch this pemmtb Lsaaed, / / —
1 shall not employ any person In any manner so as to become wbjct to the WATER SYS TR TI
Workers'Compensation Lawsof Calitmmia.Date AID
z
Z Applicant NEW REED B - Date Recei t#
Z p NOTICETOAPPLICANT:e a0er rs'Co per Ction Provisions,
Exemption,youshould become subjMmthe Worker'Compematbn provbbm of the Labor TOTAL:
W Code,you must forthwith comply with such Emmiaime or this permit shall be
DATE LU TOTAL,
deemed mvoked. B ENGFEE . 649
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE a
I bereby afRrm that there b a construction lending agency for the perform ELECTRIC FEE
n Z soca.(the workfor which this permit b lswed(Sec.3097,Civ.C.) TOTAL: .O
02 Lender's Name PLUMBING FEE _0
1L t- Mnder'a Address QTY. MECHANICAL PERMIT FEE
O W lcet Jythatl have mad thisappliationand statethatthe above Information MECHANICAL FEE
M bcorret.Iagreeto complywith all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to building cons(mtloryand herebyauthorkerepresentativesofthis
Z cityto enterupon theabmve.memioned pmperty for Inspection purposes, ALTERORADDIOMECH.
(We)agree w save,lodemNly an d keep harmless the City of Cupertino Date Receipt#
against llabilitks,judgments,mate and expenses which may In anyway accrue AIR HANDLING UNIT(TO l0,ODD CFM) SUBTOTAL'
against s n mess a of the ming of this permit
AIR HANDLING UNIT(OVER t0,000CEM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date ! EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applla est or future building occupant store or handle hanrdous HEATING UNIT CFO I OO,ODO BE"
materia l as defined by the Cupertino Municipo l Code,Chapter 9.17,and the - Date Reuel t#
Iiealthand Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,"BTU) TOTAL' 9v
0 Yes No
Will the applicant or(umre building occupant use equipment or devices VW17LATION FAN(SINGLE RESID) ISPQIy DATE
which emit h nrdous air contaminants as defined by the Bay Area Air i�1
Quality Management DiaWt7 BOELFR-OOMP DEEP OR 100,000 BTU)
4Yes 11��No
have read the baz,P materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) MAR 7 �(T�1
the(Slifornla Health&Safety Code,Sections 25505,75533 and 75536. I ,f+ + 9 1
underatand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to pally the occupant of the requirements which most be met a.�
prior to Issuance of a Certificate of Occopancy. City YI CUpel'J
•.{I
Owner or authociud agent Date .�7.a1_
1OTAL: ISSUEDBY: ` I, �Ty�������/p
OFFICE COPY