21440 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY.
Building Project Identification _ PERMTNO.
Building Address: - -/1�1 A`4
A O
5 GI44
wncre one:
17_911Z57/ CITY OF CUPERTINO-BUILDING DIVISION' p - -
at a ane:
Lie.N.: APPLICATION /.PERMIT
i - 'BUILDING-ELECnUCA PLUMBING-MECHANICAL CATEGORY CONTROL N
Archlt /Engineer
QrY ECT
LERICPERMNIT '. " FEE BUILDING PERMIT INFO .
PERMITISSUANCE ❑ .. "❑ .
LICENSED CONTRACTOR'SD RATION -
'Iherebyoffirm that lamlfcensed under proixonsoi Chaptart)(commaro, APPLIANCES-RESIDENTIAL -HON DESC ON
Ingwlth5edion7000)of Divielon3ofthe Buslnemand ProfesslonaCmde,andmy - - -
Ilcenm le In(uB tore d d(M. is PANELS n
License ClnMEO— LIc.M - j"
Date Contractor _:._1
ARCHITECTS DECLARATION' 201-1000 AMPS -
ctOZ Iadeatand my plans shall be,used as public record a. OVERI(DOAMPS,' SQ. RAR $/SQ.FT.
M
pp� O
Licensed Prafesslonal - .. SIGNSELECTRICAL 'r
G�< .OWNER-BUILDER DECLARATION - SPECIALCIRCUIT/MLSC^ t -
L.,r��i}� ,Ihereby affirm that am exempt from the Contractors License Lawforthe -
z p following reason.(Section 7031.5,Business and Professions Code,Any city or
O Z F. TEMP.METER OR POLE INST. r
F4� counlywhich requires.permit to construct,alter,Improve,demolish,or repair
any structure prior to Its Issuance,also requires the applicant for such permit to ppyygRDEVICES
.�' file a signed statement that he Is licensed pursuant to the provisions of the
Ow Contratore Lfcense Law(Chapter9(ca.r ngwlth Ssdioa 7000)o(DIv1- I
' SOS sion3oflhe Businemand Pmfemlorm Code)orthatheisexemptthereframand SWIMMING POOL ELECTRIC VALUATION.
- the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjeds the applicant to a civil penalty of nut more than OUTLETSSWITCHESHXTURES
Qflue hundred ownerdollar
he pro SQ STORIES TYPE CONSTRUCTION
u, NEW R6.SIDENTIAL ELECTR .FI'.
�n ❑I,se owner of the property,or my employees Is
with wages r their sole
< compensation,Buwilsiness
ando the Pr ie i,;.the Code:Th not Intended License Law
q far
sale(Sec 7(M4 Business and Profeml6ss Code:The Contradore License law
$$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP - RES.UNITS.
who does such work hlmaelforthrough his own employees,provided that such
Impm em nnt arenofinlendedorofferedformle.l(however,thebuildingor TOTAL:
Ymprovenkntissold wlthmoneyearofcompletloathe owner-bullderwill have " + ,
lryc�ub an of proving that he did not build or Improve for purpose of sale.). QTY.. PLUMBING PERMIT `'FEE FLOOD ZONE APN
LJ 4''as owner of the property,am exclusively cou—'Ing-an...... ppT=My�PLUMISSUANCE Y
mntradors to construct the projed(Sec.7064,Business and Professions Code: .
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN AVENT-WATER(EA)
6u llds or improves.thereon,and who contends for such plojeds with a -
- ador(s)licensed pursuant to the Contractor's License Law. - `FEE SUMMARY,
cgg(t +
I am exempt under Sea B A P C for this reason BACKFLOW PROTECT.DEVICE
S FLOOR, Y -' N
Owner - • . Date DRAINR ROOF.AREA,GOND. SARECEIPT N .
WORKMAN COMPENSATION DECLARATION
9yPER TRAP' - SCHOOL TAX Y N
FO
ereby affirm that I have a certificate of consent to self-InsureFIXTUItFS-
,or RECEIPT
�J ceflaam ofWorkeraC pareatlbn Laurance oramtifed copythereS
of(Sec. GAS -' C.40I71LEI5 PARK FEE ' ,Y N
3800
1W
,Lab C.)
'Polity •. RFCE1PTB
GAS SYSTEM- BUILDING DIVISION FEES
LP_
f ' rtifled copy Is hereby-Fimiluxis
Pprtl(ied copy Is filed with the city irapectlon GREASE/INDUSTRL WASTE 1NTURCEPTOR PLANCHECKFEE division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP -� - PAID
COMPENSATIONINSURANCE , SEWER- STORM-STORM EA.200FT. -Date : Recei t#
(This section need not he complctM lithe permit Is torone hundred dollars
(1100)nnem.) WATER HEATER W/VENT/ELECTR t� ENERGYFEE .Y ' N
I certify that in the performance of thework for which this permit is Issued, ' — '
.- I shall not employ any person In any manner so as,to become subjed to the WATER SYSTEM/TREATING '
Workers'Compensation Lawsot California.Date PAID `
ZZ Applicant - , �.
(T NOTICE TO APPLICANT: making this Certificate of Exemption,you NEW RESIDENDALPLMB. SQ.FT. Date Recel t#
:F should become subjed to the Workers:Compemation provisions ofthe Labor - - :t - TOTAL: '
0 Code,you must forthwith comply with such provlalora orthis permit shall be I
L•j deemed revoked. U DING FEE
aCONSTRUCTION LENDING AGENCY ' "{1 SEISMIC FEE
i hereby affirm that there Is a a mstrudlon lending agency for the perform- ELECTRIC FEE
.M Z ante of work!car which this permit IsJawed(Sec.3097,Civ.C.) TOTAL:, T r� PLUMBING FEE
0.:. Lender's Nerve �.
U. H Leaders Address° QTY. •MECHANICAL PERMIT ', " FEE., MECHANICALFEE
O W -1IwAffytAatlhavemadthhappUmtionandd is that theabovomformation v
C 'Ismrned.]agree tdcomply with all dtyand comy.ndloancesand state laws PERMIT ISSUANCE - i FEES PAID: - t
} relatingt.buildingornsWdlon,end herebyaWhotze represen[atives of this I -
H W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD 7O MECH.. -
�� _ (We)agree to save,Indemnlly4n d keep harmless the City of Cupertino nate Receipt#
.gamut liabilities,judgments,meta and expenses which may In anywayaccrue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
ag.inat sad City In a uence of the granting of this permit. - -
AIRHANDiINGUNIT(OVF.R10,000CFM) - CONSTRUCTION TAXI
n�
•, Signature of Applicant/Con dor �- � Date FJ(HAUSTHOOD(W/DUCT)• CONSTRUCTION TAX PAID: •
HAZARD US MATERIALS DISCLOSURE "- t
Will the applicant orfuturs building occupant store or Handle hazardous HEATING UMT(TO100,0008M, -
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date.- •Recei t#
Health and Sal dy Cod a Sed 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TAL:
4 .,O Yrs
WIIl the applicant torebuitding..pantuseequipmentordevlces VENTILATION FAN(SINGLE RESID) ISSUAN I TE
whlchemit luuardo eairmntamluantans defined bylhe Bay Area:Alr - `
Quality Management Distrf ;'p . BORER-COMP OkB'DR 100.0(p BTU) W '''
48 '?have
Yes ^^^ddd ! a,•
Ihavereadlhe Faz oua materials requimmente underChapter6.9S of BOILER-COMP(OVI7110(1,000 BTU)
the Culifomia 2ie1 h Safety Code,Sections 25505,25533 and 2534.1 - �as4,.�RFss+!-•;'4:. ,
understand that if the building does not currently have stenanq that it isat NEW RESIDENITAL MECH. SQ.FT. 19
responsibility to notify the occupant of the requirements which must be cot "
priorlo/Auance of ertiicate.fOmp.rcy. '
iver or author agen _ d Date ISSUED -
TOTALo
- OFFICE COPY