21560 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuBI Addmss:� �, AIX ' p - 21560
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in — a2 e 0 At CITY OF CUPERTINO-BUILDINGDIVISION
• c°nI am Name: , L . APPLICATION I PERMIT
E L4 / o BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLN
Arhdtect/ glneer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PER.wnssuANGE ❑ ❑.
LICENSED CONTRunder rDECLARATION
I hereby ection on 70that I)ofDt licensed ion3ofhe Bur emand ofessims 9(commenc APPLIANCESRESIDENI7AL JOB DESCRIPTION
inenseISectfon force anDiW affect.
fthe8usinessandPro(evlonaCode,and my
bens.h In s force effect. ,x 3 8 n PANELS )
License Class C- L3C.N �s .A
Date i _Contractor
—UP TO 20DAKM
CHTTECPS DECLARATION 201-100DAMPS
Q ZO I understand my phns shall be used as public records. OVER 1000 AMPS SQ.FI'.FLOOR AREA §/SQ,FI'.
U Profesiowl
G6 CLicensed SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MESE
t. G Iherebyaffirmthatlamexempt fmmthe Contract.e.Liomselawfor Ne
7 O�' following reason.(Section 7031.5,Business and Profesrions Code:Any city or
021- coup which 1 nNtrocowtmct,alter,lm W TEMP.METER OR POLE INST.
Po
�p�a anyswclurep requires
its isseance,alsorequires theappllcantfarnurh permit to
F� tl file a signed statement that he is licensed pursuant to the provision of the POWER DEDEVICES03pu Contractor's License law(Chapter 9(commencing with Section 7000)of Dwi- SWIMMING]POOL ELECTRIC E, slon3ofthe Businssand Profession Code)orihat heisexempttherefromand VALUATION
S the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for permit sub" stheapplicant to a civil 1 of not more than OUTLETSSWITCHESHXTURES
PP P 1� penalty
R five hundreddollarsof Chep). NEW RESIDENTIAL ELECTR
❑Las owner l theproperty,orhe employeswith wages their sole ` FT STOWIS _ _—TWE—CONSTRUCTION
mmpens70Kion,wBsinaaa work,aesdons Code:This e
Cmdactoentended or kens cd for '
5�D sale(Sec.7044.,Busi"m•and Profeaslon Cade:The Contractors License law
does not apply to an owner of property who builds or improves thereon,and OCC.GR0l1P RES.UNrrs
whodoessuchwork himself orthroIgh hisownemployem,provided that such
Improvements are not intended oroffered forsale.If,however,the building or TOTAL:
Improvement hsold wlthinoneyearofcompletiorytheowner-bullderwill have
t".den of proving that he did not build or improve for purpose°(sale.). QTY, PLUMBING PERMITFLOOD ZINE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor'.License Law dos not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or impress thereon,and who contracts for such plojects with a
c,,ttLLt.[[actor(s)licensed pursuant to the Contractor's Limns.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LT I am exempt under Sec. B A P C for this reason
Owner Date DRAINS FLOOR ROOP,AREA,GOND. NITARY Y N_
i� WORKMAN COMPENSATION DECLARATION RECEIPT'R
❑I hereby affirm that I have a certificate of consent to self-Inwre,or a FDCTURES'PER TRAP OOL TAX Y_ N
ocriffi360p cateCf W.rkers'Comprosedionlwursom m.mnNed copy thereoffSee. Gam, pA.gy gTpM-t INC. UTL RECEIPT'If
) [y PARK FFE Y_ N
Pocky M L(j C O �.p p / / RECm'E p
Com any_,/1/ea[ } �C s GAS EA.SYSTEM-0VER4 ) BUILDING DIVISION FEES
edified copy isherebywith
the cid. CREASE/WDUSIRL WASTE EMR PLANCHECK FEE
e Ifwdon b with the city Inspection J.-/.
L' '1".-lI�R'O.
CER IFlCA O t'TION FR N WORKERS'
GREASE TRAP - PAID
COMPENSATION INSURANCE
(rhi.ceel°n need net b°complexd ifthepecotiailure hundred dollars SEWER-SAISTEARY-STORM Date Remi t#
(8100)nilyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cent that o the performance of the work an as to
this permitis issurdi the
I shall not employ any person m any manner an s to become abject to the
Worken'Compensation lawn o(Gliforma.Date WATER SYSTEM/TREATING PAID
0 Z Appllomt
_Z 0 NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._ Date Recei t#
should become subject to the Workers'Compensation provhiow of the Labor TOTAL:
LU~ N Code,you=at forthwith comply with such pmvisiow°rthis permit shall he
> deemed revoked. BUILDING FEE
(L G CONSTRUCTION'LENDING AGENCY SEISMIC FEE
I hereby affirm thatthem is a rnntmction lending agency for the perform ELECTRIC FEE
Z ance,of the work for which this permit b Issued(Sec.3097,CIv.C.) TOTAL:
U O lender.Name PLUMBINGFEET
C) F Len mrSAderes QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O I mxct-I hat Iagree
have ready with a listlon d county
ordinances
above lntomutlon
1 hcorrn[.legree to comply with alltltyand countyoNinanres and state laws PERMIT ISSUANCE �� FEES PAID:
} W relating to building cowtroell.,. d hereby authorise representatives of this /
I— Z city to enter upon the above-mentionedproperty for Wpectionpurposes. I ALTERORAODTOMECH. 7Z OLI
— (We)agree to save,indemnify and keep harmlev the City of Cupertino Date Receipt#
against liabilities,pdgments,costs and expenses which may in any wayacaue AIRHANDLING(MIT(I'Ol0,0DOCFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
".;L— LZZZZZ_f AIR HANDLING UNIT(OVER 18000 CF.M) CONSTRUCTIONTAX
S urco ppl cant/Con rector Date -W D(HAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllitheappilsnt orfumre building occupant store or handle hawNon HFATINGUMT(T0100,"BTU) '
materelas defined bythe Cupertino Munlcipai Code,Chapter9.IZand the _ Date Recei t#
health and Safety Cod,Section 25532(a)7 HEATING UNIT(OVER]00,000 BTU)
❑ Yea l�No TOTAL:
Will the applicant or future building occupant use equipment or device I VENTILATION FAN(SINGLE RESID) Sed ISSUANCE DATE
which emit haea reous all conhmlw ots as dented by the Bay Area Air
Qu Iity Management Distictl BOILER-COMP OFT'OR 100,000 BTU).
4Ye No
h Yes read the h aQ� malenah equirementsunder Cha Pier 6.95of BOILER-COMP(OVER100,000 BT U)
the Glltornia Health kSa(ety code,Section 2550.5,25533 and 25534.1 'I
u ndemtand that if the building doe not ormntly have a tenant,that it is my NEWRESIDEMIALMECH. SQ.R. -
rapotolases..of. anificte the of of the requlmmentswhkh must be met Dec' "PC�
prior t°issuance cat s Certlticate of Decvpanry. N
+ A KRA
Owner or aulhonaed agent pate a
TOTAL: s LULDB
OFFICE COPY