21371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMITNO.
Building AA R, �. sir £ 21371
n ame:� S u lie: A A A
CITY OF CUPERTINO-BUILDING DIVISION 10- -2) x_90
r contra m Name:(', Lic.No: APPLICATION / PERMIT
A O BUILDINGELECTRICAL-PLIMBINC.MECHAMCAL CATEGORY CPNI� O
ArcFite gineer. Llc.No: �pL
L SSOCI BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address, ,02-- QE93W D)( S Y PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(co.mene APPLIANCESRESIDENIAL JOB DESCRIPTION ion7000)of DiAsion3ofthe Businessand PmfemionsCode,andmy '
license 1s ill f and effect ail^l PANELS
Llce..0 Lica !}J. IOx�� I
Date_ Contractory/'l R95
ARCHITECTS DECLARATION 201-1W0 AMPS
po!Cg�7N I understand my plans shall be used as public records. OVER iWO AMPS SQ.IR.FLUOR AREA S/9Q.FT.
u
FiX Licensed Professional SIGNS ELECTRICAL �'1(, / 1 f Z0,00
«<<� kOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC �s
7E, Iherebyaffirm that I..exempt from the Contractor's License law forthe
O following reason.(Section 7001,5,Business and Professions Code:Any city or
F F'8 county which requlresa peronwoostruct,alter,improve,demolish,orrepair TEMP.MEEK OR POLE INST.
.a anystm=mpAortoiULasrancgaLsorequtreatheappbantlorsuchpermitto 3 POWER DEVICES 6 file a signed statement that he is licensed pursuant to the provisions of the
8 O w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC sion3 of the Business and Professions Code)or that he s exempttheerfrom and VALUATION
Yd S the basis for the alleged exemption. Any violation of Section 70015 by any
g� appnesntfora permit subjectatheapplicanunitcivil penalty ofnot romethan OUTLESSWTCIIFSFUTURES
five 1,as o nerdolof the M.
pro NEW RESIDENTIAL ELECTR SQ,
7�n ❑Las owner of the property,or he employees in with wage as[herr sole STORIES TYPE CONSTRUCTION
< compensation,will doBlume sahe work,andthestructe:TheC emittintended or offeredLaw
O dile(Sec. pply to ainowand Professions Cod e:TheCimprovrs License Law
$ donna apply roan imserofpmpgh his o W this nempl rimprwvidedt at andwhoOCC.GROUP RIS.IIMTS
[mpd eseuch nhimsenorthroffe hisowmte.lFh weprovidedthatsuch
Improvement issold intendneyearfcomprsale.theh evegtheerwilI have
T `
Improvement scold withinoneyearofcompltiogtheowner-bu0derw111 have
t Men of proving that he did not bund or improve for purpearo!sale.). QTY, PLUM13ING P'01111T 1A FIAODZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec,7044,Business and Profesalom Code:
The Contractor's License law does not apply to an owner of property who
WildsALTER-DRAIN&VENT• ffNN
or Improves thereon, and who contracts for such plujects with a
cgo_t actorve
s)licensed pursuant to the Conctors License Law. FEE SUMMARY
I,-.J I am exempt under Sec. B&P C for the reason BACK PROTECT.D Oil�IDLFLES
Owner Date DRAWS IL IF GO SANITARY SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT It
0
1 hereby affirm that I have a certificate of consent to self-Insure,or a 1'ttNRFS' \ SCHOOL TAX Y_ N_
certificate of Workers Compensation❑durance or a certified copy thereof(Sec. RECENT'a
3800,Lab C.) GAS F.A. O PARKFEE Y N
Policy I
Om RECEPT M "
Gany GAS ST
FA.SYSTEM 4(EM L
[rcertincd copy s herebyth the city
DING DIVISION FRES
Inspection d. BUIGREASE/INDU WASTE INTERCEPTOR PLANCHECKFEE
�JCertHled copybfiled with the dry divlslon. '
W CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAIDId—�j�'9� �
COMPENSATION INSURANCE
(Thlssectlon need not becompleled lithe permit s forone hundred dollars SEWER-SANITARY-STORM EA."Fr. Date Reeei t# IIlb'go
(S100)oify that
WATER HEATER W/VENT/E,ECTR ENERGYFEE Y N
I certify thato the person
in any
manner
for which etupermit csewed,
I shall not employ any person In any manner ao u to become subject to the I�M
Workers Compensation Laws o(Callfomla.Date WATEi SYSTEd/TAEA'IING PAID[0-41-709
0 Applicant I-70 :;
Z O NOTICETO APPLICANf:IL after making the Certifirale o(FiempHon,you NEW RESIDENTIAL PLMB.__SQ.FT, Date Re— t# 9,q,M
should become subFct to the Workers Compensation provisions of the Labor
N Code,you must forthwith comply with such provisionsTOTAL:or this permit shall be ,lam
LU > deemed revoked. BUILDING FEE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby afflrn that there s a construction lending agency for the perom, TOTAL: ELECTRIC FEE
O ance of the work for which this permit s Issued(Sec.3097,Civ.C.)
(,) Lender's Na
PLUMBING PEE
Iy F delsAddm s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythat I have read thlaapplicattonandaatethat theabove Information
0. iscorred.I agree to comply withal]dtyand county ordinances and nate laws PERMIT ISSUANCE FEES PAI D:
} U) relating to building contructlon,and hereby authorize representatives fifths
F Z city to enter upon the abovcmentioned property for Inspection purposes. ALTFRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgerens,costa and expenses whichmaymanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) $UBTOTAL-
against said City in cOnsm of the granting of this permit.
n%2 QS/N�.._ iahl11n AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
sign of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thea pplicsrat orfuture building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Health and Silcty Cede Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
O Yes M No TOTAL:
Will the applicant or future building occupant use equipment or devices VENDLATION FAN(SINGLE RESID) IS$Ei'ARs((pjyA•LE
which emit hazardous air contaminants m dented by the Bay Area Air G'.:d'$aTC±
Quality Management Mind? BOILER-COMP OEU'OR 100,1XU BTU)
4 Yet 9 No DEC 101 990
havereadlhehaza f&yC encs re..255cnsunder Cha pte4. I of F101LEI2-CO Mp(OVERIW,000BN) NGLs
the California HealthkSlfdy Code,Sections 25505,75533 and 7553E. I
understand that lithe building does not currently have a tenant,that It s my NEW RESIDENTIAL MECH. yj,pT,
responsibility to notify the occupant of the requirements which must be met /a.Hv M
pnortoL uancedaCediflcateof Occupancy, '�+L4/ V4
ot
Owner or authorized agent Date �{�1J'�,-��'
TOTAL: ISSUED B4.��-1r��C1�R''�V�P�
OFFICE COPY