21552 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMT'NO.
Building Addre,,: 0 �o 21552
are came: q{ one: -
'C e m ZSZ Z,29 CITY OF CUPERTINO-BUILDING DIVISION �D
G° _ N APPLICATION /PERMIT
'1 carr O ,�Z UI
BLDINGELECTMCALPLUMBING- CATEGORY CONTROLM
Architect/Engi er. Lt.Nre MLCHAMCAL
QrY ' ELECTRIC_ PERMITFEE ' BUILDING PERMIT INFO
Address: PERb11TISSUANCE ].CO- •� ❑
LICENSEDCONTRACTOR'S DECLARATION -
Ihereby affirm that lamoicensedunder provlslonsofChapter9(oommme APPLIANCESRFSIDENTIAL JOB DESCRIPTION
Ingwith 5ectloo7000)of 1Avisinn30fthe Buslnessand ProfessiansCode,and my
license Is In fun fo and effect. PANELS -
Li Dllte Cla Cmdr 338"592.
Dale Contnnor
ARCHITECTS DECLARATION 3111-1000
rcC2C Iunderstand my plans shag be used a public records. OVERI000 AMPS F'r[00R AREA $/EQ.FT.
00
(J Licensed Professional SIGNS ELECTRICAL E D , ;'
:N OWNER-BUILDER DECLARATION - SPECIAL CIRCUIT/MISC J 1
7F'��a 1hereby affirmthat Iamexempt from,the Contractor'sLicense Law for the V -r +
.Ogo following manon.(Secoon70315,Business and Profesons Code:Any city or 7 C
7PMP.METERORPOLE INS7.
countywhichclum requlresa permRtomrmact,orequi theapmve,demollah,ormpairmitto _
any atacturc pricutaten mts hat he Is licensed
Pursuant t the provisionorstach s
of
a POWER DEVICES
�a. floe a signed kens eLa that he la r 9(Co d pursuant it the tion 7000) of the ,
3w Mon 3 ofths LicenseLaw
andPrhapter9(cornmenciog)orthat with Secxamp"herefof,ivl-and VALUATIONO��'
,"•SOS tlon3o(theguslne,s and Profemloru Code)orthat he6exemptthere(mmand MING POOL ELECTRIC
r5pi 6 5 the basisfor the alleged exemption. Any violation of Senlon 70)1.5by any OUTLETSSWITCH SFD(TURFS /F //
applimntfor a permit subjects the a pplicant to a Civil penalty of not more t ban 1 U V
C, rive hundred dollars( M.
❑I,as owner of the property,or my employees with wages as their sate NEW RESIDENTIAL ELECTR_SQ.FT. Sf RI. TYPE CONSTRICTION
compenaatlon,willdothe work and thestrunure is not intended or offered for I
.D sate(sec.7044,Business and Professions Code:The Contractor's License Law
$ does not apply to an owner ofproperty who builds or improves thereon,and OCCGROUIa RFS.UNITS
whodoessachworkhimselorthrough hisovvnemployesOCC.
CROUP,provided that such ,
improvemenl issold withinoneyearofcompocllorytheownei-buRderwlll haveImprovements arc not Intended oroffered roe sale.If,however,ihebulleing or TOTAL: l!)
tlrden of pmvingthat he did net build or Improve forpurpowofsakJ.
t� QTY, PLUMBING PERMhF, 'FEE FLOOD TONE APN
L as owner of the property,am exclusively Contracting with licensed PERMIT ISSUANCE'
Contractors to contact the projM(Sec.7044,Business and Profesloa Code: lYl•
The Contractor's License Law does nor apply to an owner of property who -37—
hoALTER-DIRAW k VENT-WATGR(FA)
Wor Improves thereon, and who Contracts for such p(ojects with a e 8 FEE SUMMARY
o�Bf[�Cents)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec B k P C for this reawn
OUTSIDE FEES
Owner Date - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• - RECEIVE
WORT that COMPENSATION DECLARATION pp(NgEg I'FR TRAP &4,00 SCI100L 7A% Y_ N
❑1 hereby affirm that I have a re suratu of consent ci seB2nnre,ora RECEIVE It
3800,Lcertifieab of Worken'Compeaatlanlruursnreora certified copythemo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS. PARKFEE Y N
3800,Lab C.I —
Polley p DING DI N
GAS EA.SYSTFMAVER 6(FA)
' C m any BUILDING DIVISION FEES
diried copy is Hereby furnlehed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Cedifled mpylaflled with the city lmpectlon divltlon., l��,,//1 ��F,.,'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 2/I_?o C"/V A l y
COMPENSATION INSURANCE ""--
(Thissenion need.ot CO be Completed ifthepmoit is(or orae hundred dollars SEWER-SANITARY-STORM EA 20OF1' Date Re It#
($100)orlessJ WATER F@i3TFR W/VENT/dECTR ENERGY FEE Y _ N
I mnify that in the performance of the work for wMeh thla perrrdt is luued,
I shall not employ any person In any manner an as to become subject to the 1 WATTR SYSTEM/.IRFA.DNC z
Worker' Laws
Compensation of California.Date ( a PAID
O Z Applicant RESIDENTIAL PLMB._SQFf. Date Recei t#
Z O NOTICE TO APPLICANT:](,after raking this Cernflnte of Exemption,you
Hshould become subject to the Workeri Compeaatlon provisions of the Labor _ TOTAL;
NCode,you mu,t(odhwith Comply with such provhloa orthla perMlehall be
W > dmmedrevoked. MLDING FEE• . d0
O 'CONSTRUCTION LENDING AGENCY - SEISMIC FEE c�
tl Z Ihercbyafflrmthattherc lsematactlw lendingagenry(onhe perform- - TOTAL: ^ 00 ELECTRIC FEE
7 ance of the work for which this permit i,lsucd(&c.3097,Civ.C.) - - 04,61
U O Lender's Name PLUMBING FEE pZ .$0
LL F Lender's Add res MECHANICAL PERMIT E MECHANICAL FEE
OW Icedifythat l have read thbappBoti°�and orate that theabcve information
fIJ is Correct.I agree to comply with all ntyand County ordinances and pate laws ITLSSUANCE FEES PAID:
>. 'relating to buildingcosteaction,and hereby authorize repreentativn ofthis
F in city to enter upon the above-mentioned property for Inspection purposes. AkER OR ADD TO MECH..
_ (We)agree to save,Indemnify an d keep harmed,the City of Cupertma Date Receipt#
against olabilltles,judgments,cast aanaexpenses which may In anywayacaue AIR NDLING UNIT(TO 10,000 CFM) SUBTOTAL: e.6
ago W Ity In on a o(tyyunt Ing of this permit.
• /z Alft HA uNc uMr(OVER 10,0054m) CONSTRUCTION TAX
IgnamrcotA I am/Contractor' 11 Date l�. IXtfAUST D(W/DUCE CONSTRUCTION TAX PAID:'
AZARDOUS MA ]ALS DISCLOSURE
Will the applicant orfunam building oceupant store or handle hazardous HEATINGU (TO100, TU) Date Retei t#
material Mt defined by the Cupertino Municipal Code,(hapter 9.1$and the
liallh and Satiety Cod Section 25532(a)7 HEATING UNIT( V w,000 BTU) TOTAL:-
❑ Yea o '
Will the applicant or tore building ocmpact use equipment or devices VENTILATION F INGLE RESID) ISSUJWATE
which emit harardou,air cont.mumnaf as deflned by the Day Area Air ��
Quality Maagamcnt D't' - BOILER-CO DHPO 00,1100 BTU)
I�
[?h Yrs No
avcread lealth a ore materials requirements 2555,2553 aChapte4. I of BOIL[R- MP(OVQR 100, BN) py
the Gll(omla Health k$afety Code,Sections 75505,25533 and 75534. 1 s j T $ '
understand that lithe building does not Currently have atenant,that of is my NEW✓ ESIDENITALMECH. SQ.hT.
nspmulbllity to notify the occupant onhe requirements which most be met
Prior to Issuance ofd Certlfiew.foccupancy. _ MW �•r s. _
v
Owncrorauthoriredagent - Date - ISSUEDBY: H oIAUCL 1�
TAI:
OFFICE COPY