21551 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ingAddress
911,06 tip e-t-�eC�tcti1 ' `�. " 21551
Phone:
A A A
TA,A, �✓Ik L�-�
eat CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT'Ilk':"11;`L_ Lit. .l 10
�[ BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lec.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: t NPERMITISSUANCE TL—aI PLUMB =a:Fl
LICENSED CONTRACTOR'S DECLARATION D El
I hereby affirm that l am licensed under provWons of Chapter 9(mmmenc- APPLIANCESRESIDENTIAL
JOB DESCRIPTION
Ingwith5ection 7000)o(D,Ws,on3o(the Bualnevand PmfnsionsCade,ond my
I icense is in(ul fo d dfett. ' s. PANELS r-•I �. 1
Limn Class — Llc p 5 �L L ^ cO
Date Cormactor a..— Ys
ARCHITECTED CLARATMN MI-1000 AMPS
��+qq+++a0 OC I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E%Z tLuj Licensed Profess,osil SIGNSELECTRICAL
�n¢G OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
F' � 1herebyafflrmthat l am exempt fromthe Contractor's License LAw for the
(allowing reason.(Section 7071.5,Business and Professions Code:An city or
Fg county which requires a permit tocommict,alter,Improve,demolish,orreair TEMP.METER OR POLE]NS.
anystmc mprbrtoibbsrame,aLorequimatheapphmntforsuchpermitto
file a signed statement that he b licensed pursuant to the provisions of the ]OWER DEVICES
Contractor'sL,cense law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
Os s1on3otthe Buslnessand ProfemiomCode)orthat he is exempt therefromand VALUATION
G5p1 the basis for the alleged exemption. Any violation of Section 70315 by any oLT /4(e,
applicant for a permit subjects theippliccunt to a civil penalty of net morethan -ETSSWITCHESFll(T11RES l FMX)
a five hundred dollars($500). - NEW RESID ELECTR
❑I,as owner of the pmperty,or my employees with wages as their sok EQFr. STORIES iYI'E CONSTRUCTION
C ¢ compensation, in
will clothe work and thestmco a is not intended or offend for
5` D sale(Sec.7044,Busess and Pmfenions Cade:The Contractors License IAw
(�,1 $ don not apply to an owner of property who Wilds or improves thereo,and RESUNr15
.
❑❑ who doessuch work himselforthrwgh his own employees,provided that such OCC,CROUP`
improvermotsare not Intended oraffered forsale.If,howevepthebuildingor TOTAL: J lO
improvement eseld within oneyearofcompletion,the owner-bullderwili have
the bnle.of pmvingthat he did not Wild crlmpnwe for purpose of sale.). FLOOD ZANE APN
QTY. I ERM T FEE
I,as owner of the property, Se exclusively contracting Pro with licensed sCode: PERMIT I E
contractors to construct the project(See.appy Business and Professions protons Code:
The Contractor's impr's License Lawon, does not apply to, f owner d property who ALTER k WA
Wilds 1, improves thereon,and who coruruats ice sech projects with a
cQtLtraaor(s)Banxd pursuant to the Cgntractor'e License Law. AIX PR ECT EVIG FEE SUMMARY
L.J 1 am exempt under Sec B k P C for fhb reason
OUTSIDE FE17S
Owner D ODF,A SANITARY Y N_
Date RECER'1'X
WORK MAN CO have
acomTION DECLARATION SCHOOL TAX Y_ N_
❑1 hereby affirm that I have•cemRote of consent to op(therre,(S a
certificate of Workers'CompensanlgnInsurance or a certifledropy thereof(Sec. RECEB'C M
3800,Lab C.) atis EA. -]INCA 0UIL PARK FEE Y N
Policy X RECEIPT p
C GAS EA.SYSTEM-OVER 4(EA)ff1BUILDING DIVISION FENS
ertified copy b hercbytthe cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy b filed withh the city inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' . GREASETRAP PAID
COMPENSATION INSURANCE
TThisecolon need not becompid,di lithe permit bforonehundred dollars SEWER-SANITARY-STORM EA.ppFT. Date Recei t#
(F100)orless.) WATER HEATER W/VFM/ELECTR ENERGYFEE Y N_
I llcertilythat
employ
o the performance of the work for which fhb pirrolt c booed,
I shall not employ any person in any manner at es to become subject to the
Workers Compensation lawn of California.Date WATER SYSTEM/TREA7TN'G
O Z Applicant PAID
fter
Z Q should NOTICE TO esubleAMaf,Workers
this
sationlateof Exemption,you NEW RESIDENTIAL PLMB. SQb7. Date RTA t#
shouldbecome forth tithe Workers'Compensationprovbionsofthe Labor TOTAL:
LU~ W Code,you rover forthwith comply with such provblons or this permit shall W
> deemed revoked. BUILDING FEE
CL a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there's a construction lending agency for the perform ELECTRIC FEE ?j Q
7O ante of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL:
LL Lender'.Name PLUMBING FEE
Iy L) der'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icect.Ia reetoc comply
with allcitlond cuntyoft1 heabove lnfomvationaws
C roingt building commuctioh allcityhereby
auhortan nanceaand state laws PERMIT ISSUANCE FEESPAID:
} N relating to building mnsnmct,on,and hemby aunhorlxe representativen ofthla
H Z city to enter upon the aWvg-mentioned property for Inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,Ind or an d keep harmless the City of Cupertino Date ReCe1Pt#
agaWtlab,lities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(To 10,000 CFM)
ugal Id Cit consryuence of the gra ming of this permit. SUBTOTAL:
t AIR HANDLING UNTr(OVER I0,,0kcFM) CONSTRUCTION TAX
Sign taro of App cant/contractor IJ Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle baurdous HEATING UMT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the Date Recel t#
Healthand Safety Codr Sectlon 25532(a)2 HEATING UMT(OVER 100,000 BTU)
❑ Yes . M No - TOTAL: p c
Willtheapplicant or future Wilding occupant useequipmentordevices VENTILATIONFAN(SINGLE RFS TO) I$$IjpTIX(�yJQA•1•E
which emit hannious air comimlrants us dented by the Bay Area Air u
O",silty Management District? BOILER-COMPPFNOft1W,0(tl gTU) �+
es
hve aread the hada ous Rstetlab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) r y s�
the California Health A Safety Code,Sections 75505,25533 and 25534. 1 1990
understand that if the building does not currently have a tenanh that it is my NEW RESIDENTIALMECA. SQ.FT
responaibility to notify the occupant of the requirements which most be met
prior no issmnce of a Certificate of Occupancy.
Owneroraulhoricaaagent Date
TOTAL: ISSUED
OFFICE COPY