21301 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I .PERMIT NO.
Building Address:r7 J _y ` H t+Ev.IQ no q fa Q. 21301
zM_ne17ante: - e: A
FI✓?931x It 7..D�--(otOg CITY,OF CUPERTINO-BUILDING DIVISION
ca" ctor'. ams: # L19.No APPLICATION / PERMIT
zD e a BUILDING-nECTRICALnUMBINGMECHAMCAL CATEGORYCONTROL If
Architect/Engineer.- Lk.No;
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERFIITISSUANCED D
' LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that I sm licensed under provisions of Chapter 9(commenc APPLIANCFSRESIDEMTAL JOB DESCRU-FION
ingwhh SectiOn7000)o1 DivhJcn3 ofthe Buslnessand Pro(enionscode.rvi my - s.
license Is In full .. effect. _ PANELS• ,{ j�
License Cls Lic#
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMP5. \ l
Q�p�uu000 ,Iuhdemtand my pians shall be used as public records. OVER 1000 gMPSx - elii SQ.FI.FLOOR AREA $/SQ.Fr.
E f0 Licensed Prv(ealmaI SIGNS ELECTRICAL,•
GGGG'�- LL7 OWNER-BUILDER DECLARATION
Ihereby affirrnthat lam exempt form the Contractor's License Law for the SPECIAL CIl2CUIT/2,119C /}
r4.,o following tenon.(Section 7¢11.5,Business and faro(essbne Code:Any city or 1 art V'i
countywhich requites.pemdttocontorct,altepimprove,de=Ush,orrepair 'IFNp•-METERORPOLE INSp: fi
$$'°� anystmciure'ptlorm its issuance,alsorequlrealheapplicent forsuch permitto .y,
i file a signed statement that he is licensed pursuant to the provisdors'of t e POWER D1ZgCES _ \
Contractor's License Law(Chapter 9(Commencing with Section 7000)of Dl 1tl a
�O s1..3 ofthe Business and Professiora Code)orthe he ianempt therefrom. SWN1 GIOOLT, ECTRIC VALUATION
the basis for the alleged exemption. Any violation o(5MIon 7¢f 1.5 6y an
applicant for a permit subjects the applicant to a civil penalty of net morothaW
LETSSWITCHFSF7XTURFS
five hundred dollars($500). RESIDEN]t ELECTR '
�n ❑I,as owner of the property,or my employees with wages as their sol - - •� STORIES - TYPE CONSIRUCTIONcompensation,will do the work and thetructure 1.not intended or offered foIjO sale(Sec.7094,Business and Professions Code:The Contracioes License La$ docs not apply to an owner of property who builds or improves thereon,an �/� 1 "1j OCC.GROUT' RES.UNRSwho docs such work hdmeelforthrough his own employees,provided that sucimprovements are not intended oroffered forsale.ILhoweventhebuiidinge �/ i°`o TOTAL:improvement bsoldwithin.neycarofcomplctiogtheowner-bu0derwill havtl)9�,�Srden°f proving that he did not build or improve for Purpose of sale.). PLIJM$ EICM FT,OOD 7pNE APNU 4 as owner of the property,am exclusively contracting with licensedTT LSSUANCE -contractors to construct the project(Sec.7014 Business and Profesdom Codea The Contractor.License Law don not apply to an owner of property whbuilds or improves thereon, and who cotracts for such Ained(,with aR-DRAIN&VENT WATER(EN,,ttlB[��actor(a)licensed pursuant to the CntractoYS License Law. FLOW PROTECT. EVICE FEE SUMMARY
eLlI am exempt under Sec. B &P C'for thisreasnOwner Date INS FLOOR ROOF,AREA,GOND. SANITARY Y_ N—
WORKMAN COMPENSATION DECLARATIONrs� RECEIPT#
❑I hereby affirm that I have a certificate of consent to self-insure,or aRES PER TRAP lip' (� .SCHOOL TAX Y_ N—
certificate of Worker!Compensation Insurance or a certified ropy thereof(SecRECEOT38M LabQ ,L/� GAS-FA-SYSTEM-1 INCAOUTLETS PARK FEE Y N
Policy# S( �/'�Q�/ /J RECEIPT#
Com any �~� GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
Certified mpy is hercbytumecity GREASE/INDUSTRL WASTE INTERCEPTOR 'PLANCHECKFEE
❑Certified copy 6 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' ' GREASE TRAP PAID
-
COMPENSATION INSURANCE - SEWERSANITARYSTORM B.A.200FT Date ReDaal tiY
(This section need not becompleted lithe permit l9(Drone hundred dollzn
($100)orless.) (NATER HEATER W/VENT/ELFCTR ENERGYFEE Y N '
I cen.t.r pInthe promsnce of ehework(orwhkhthis pertNtis Luued, —
I shall not employ any person In any ner so n m bec su o the
Workers'Comppyp�paaaN!1orn�]L,aa o( rynla. to WATER SYSI'FM/TREATING PAID
O Z Applicant %eH
Z O NOTICE TO PLIC :If,after making this Certificate of Exemption you NE'WRESIDENITALPLMB.__SQ.FT: Date Recei tit
Fshould become subject to the Workers''Comperuatlon providers of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this pemot shall be
LU > deemed revoked. BUIL NG FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffimnt)at there re a coretroetion lending agency for the perform- I LsU� SETSELEERIC FEE
n Z' anceoftheworkforwhkhthispermtls inued(Sec.3097,C1v,C.) TOTAL: "T
V O Lenders Name PLUMBING FEE Q
LL I— Lendce.Address QTY. MECHANICAL PERMIT FEE
O O lcertify that I have mad thts applicatian and state that the above Information MECHANICAL FEE
1 iscorrect.I agree to complywdth all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} Wrelating to building rootruction,and hereby authorize representatives of this
(— Z city to enter upon ten above-rrenBonnd property for Uspreion purposes. ALTERORADDTDMECH.
— (We)agree to save,indemnify and keep harmless the City of Cupertino - Date Receipt#
against liabilities,judgments,contsand expenses which may In anywayaccrue AIR HANDLING UNIT(To 10,e0O CpM) SUBTOTAL:
against_ consequence of thio
Id City donein permit. -
`X^-- Ti f � AIR HANDLING UNIT(OVER i0,000CFM) CONSTRUCTION TAX ,
wAn nftx.(Appa.WConmacmr D—a%, EXHAUST HOOD(W/DUCT) CONSTRRTOPA
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tN
ent erul a.defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
F1Yes No
WI 1l the applicant or re building occupant use equipment or devices VENTILATION FAN(SINGLR RESID) ISSUANCE DATE
which cent hazardous air contaminants as defined by the Bay Area Air
Quality Mawgement rNo BOILER-COMP(3HP OR 100,000 BTU) �Q
4 Vee No
have read the hazy Tet materials requirements 5533underaChapter.1 of BOILERCOMP(OVER]00,000 BTU)
the California Flealih&Safety Code,Sections 25505,25533 and 75534,1 '
under.tand that iflhe building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. - SQ.R ��� r 1 9p
responsibility to notifyCCC RTTt��hrttt omepant of the requirements which must be met
prior to issuance fa Ificat Occupa cy.
wner or aut or .gem
ODte• . ISSUE `e�p C
TOTAL:
OFFICE COPY