21569 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
BuildingPlead Identification - - PFY.WTNO. .
Building Address,
wet, cLl��rh � c� 9so�`� 21569
nen ems: 1 nAPPLIC ATA
GHr j �/d I ys5'i `7n CITY OF CUPERTINaoU1LDINGDIVISION . ` �� C
Gntnctar.Na Lic.No: APPLICATION / PERMIT
BUG
ILDINELEL
CTRICAPLUMBINGMECH LAICAL CATEGORY CON}TQvfg
Architect/Ggineer. Lle,Na: (SDJ CJ
QTY ELECTRIC PERMIT • (IEE BUILDING PERMIT INFO
Addreac .. PERMIT ISSUANCE;•'1
LICENSED CONTRACTOR'S DECLARATION - _ -
Ihereby Affirm that lamlicensed under provWonsof Chapter 9(oummenc APPLIANCFSRESIDENTIAL - ]OB DESCRIPTION
ingwlthSe ion7000)of Di"slon3aftheBusiws d Pro(atloneCode,and m - - �,^N--1�
license le In full to.and effect. PANELS - y--aF' 3
License Class Lic.N
Date ' Contractors
ARCHITECTS DECLARATION - 201-1000AMPS
s4 7 I understand my plans shall be used as public records, OVER 10DO AMPS �. ,SQ.Fr.FLOOR AREA S/SQ.Fr. -
OO y
SIGNS ELECTRICAL L' W �•s 2
Z Licensed Professional
<�E+1 OWNER-BUILDER DECLARATION
Fi+ - SPECIALCIRCUIT/MLSC
Z p., Iherebyaf(Irm that am exempt from the Contractor's License Law for the -
o following reason.(Sectlon 7031.5,Business and Professions Code:Any city or
O z TEMP.METER OR POLE INST.
P countywhlch rcqulresa permit lomNuwp al
cter improve,demoBeh,orrepair ' + -
'y(� anystructurepdortolblesuanc,,elsomqulrestheappllantforsurhper tto POWER DEVICES +
E file a signed statement that he h licensed pursuant to the provisions of the 9
SOSContneorb License (ChapterLaw 9(commencin ith Section 7000)of Divi- VALUATION
elon3ofthe 8usinessand Pcofelom Code)°rtha8hahekempttherefcomand SWIMMING POOL ELECTRIC —1,,s,
6 5 the bash for the alleged eaemptlan. Any Wolation of Section 70315 by any �vs�, OUTLETSSWITCHESFIXTURFS .i.� ?, (( 2
O appgcaN(ora perMbubjecte tFe applMant toss civil penaltyof not..than - b� e
end
five hundred nerofdeltashepr. NEW RESIDENTIAL ELECTR__SQ.FT, STORIES TYPE CONSTRUCTION
�n ❑7,as owner of the property,or my employees with wages as their sole
compensatlon,wllldothe work and thestrocture isnot intended of offered for
q M -In&c.70K Buionesand Professions Code:The Contractors Licerue Law
RSA does not apply to an owner of property who bulls or improves,thereon,and
E who donsuchworkhi.Uorthwghhi..nemploym prwldeathatwch PCC GROUIa RFS.ANTIS
Imp!Vvemenh arc not Intended oro(fered for sale:If,however,the building or TOTAL: s '
Impromo
vent bsold within oneyearo(complellon,the owner-budderwill have
1t15ysrden of proving that he did net build or improve for purpose of sals.). QTY, PLUMBING PERMIT FEE DOD LONE' • APN
`o,Ir.,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ry � '
ntractors to construct the project(Sec.7044,Business and Pm1coloru Code:
The Contractor's License Law does net apply to in owner of property who t ALTER-DRAIN&VENT-WATER(EA)
builds or Improvn thereon,and who contracts for such pPjects with a ` '7,
tt do,(sI licensed pursuant to the C.m.eore License Law. BACK FLOW PROTECT.DEVICE 'FEE SUMMARY
LII am esempt ec
under S . B& P C for this reason
DRAINS FLOOR ROOF,AREA,COND.• SANITARY Y N
Owner Date _ RECFRPf N
WORKMAN I have A COMPENSATION DECLARATION FAI'URES PER TRAP �� SCI{DOL TAX Y N
❑I hereby affirm that I have o lesurne of consent to sell-insure,ors ` RECEIPT N
c8001L.eofWorken'Compevatlon lvuranee ora certified copythereof(see. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Cc a GAS EA.SYSTEM.OVER 4(EA) DINGRECEDIN
Cc any - BUILDING DIVISION FEES
I"certf0ed copy la hereby th thhity GREASE/INOUSTRL WASTE INTERCEPMR ,- PLANCHECK FEE '
CertlBed copy h filed with the city Iropectlon division. P�7
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASETRAP ' le]-sl rYd �(
PAID
COMPENSATION INSURANCE
(TMs section need net be completed if the permit h for one hundred dollars SEVER-SANITARY-SNRMEA'XIOFT. - Date Recei t# 33+10
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertify that In the performance of the work forwhich this permit I.Issued,
, r �y—
I shall not employ any;person In any manner so as to become abject to the WATER SYSTGf/TREATING Z,—�'(--(() SC(51j0
Workers'Compensation Gas o(GIIlomb.Date - PAIDI
O Z_ Applicant ^ m
Z O NOTICE TO MPLICANT:I,ager making tNs Certllate of l3xemptWn,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t# /�r
Hshould become subject to the Workers'Compewt Ion previsions of the Labor TOTAL: 1t7
.� f/1 Code,you must fort hwith comply with such provisions or this permit shall be G)8
W ] deemed revoked. 1 s�
a � CONSTRUCTION LENDING AGENCY SEISMIC FEE I I
I hereby affirm tthis hat there is a construction lending agency for the perform ELECTRIC FEE
Z ante of the workfor which s permit is Issued(See.3097,Civ.C.) _ TOTAL: cru 1
V O. Lender's Name PLUMBINGFEE aQ7
<L F- Lenders Addmes QTY. MECHANICAL PERMIT FEE MECHANICAL-FEE
OW Icertifiethat l have readthhappliation and state that theabove Information
a hmrree.]agrccto complywlthallcityand county ordmanasand tlate]awe I PERMIT ISSUANCE Cs� FEES PAID:
relating m building oneatruction,and hereby authorlee repeesntatives of this -
I— Z city to enter upon the abova menlloned property for inspection purposes. ALTER OR ADDTO MECH. 2Q7
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Dale Reeej t#
L) agalnst liabilities, menta,costs and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,(X)0 CEM) SUBTOTAL:,
'gains Id Cit niryuence o(the an i.9.fthl.permlt _ ,
N , / !� / AIRI{ANDLING UNH(OVER IO,000CFM) CONSTRUCTION TAX
Ignotureof Applicant/ trader Date EXfHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HA DOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant stole or handle hazardous HEATINGUNIT(TO100,000BTU) �'
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Date RCCCj t#
I lea11h and Safety Code Section 25537(a)7 GATING UNIT(OVER 100,000 BTU) .TOTAL:
r Yes. I]No -
Willtheappllantorfuture building occupant use equipment ordeAces VENTILATION FAN(SINGLERESID) IT,� ISSUANCE DA'L'E
h . .
which emit azardous t lr mntaminara ae deflned by the Bay Area Air
Quality Management D❑istrint7 - BOILER-COMPOHPOR 100.000 BTU) RAM
4 Yea rd No
have mad the hazy oeuleyrtutcdals requirements under Chapter6.95 of BOILER-COMP(OVFR 100,0008TU) JAN
the California Health&Sof Code,Soelons25505,75533and25534.7 AN O V4
understand that if the building does not currently have.tenant;that it is my NEW RESIDENTIAL MECH. SQsT
respprior to Issuance
nor Certificate
of o(the rcqulrcmenb whkhmust be met �� 'f
prior to issuance of Grtlfiale o(Ocmpancy. 0
Pry
Owner r awhorlend agent - Date
ISSUED BY
TOTAL: I :
OFFICE COPY