21777 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—' USE BALL POINT PEN ONLY
Bualdi.&Project Identification - PEIAHTNO.
building Addrega � - 21777
wnera ame: one:
s 3-• CITY OF CUPERTINO-BUILDING DIVISION A
Can, "'"1G1 - Lt..No: - ' APPLICATION / PERMIT '���Q
BUILDINGELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ .❑.
LICENSED CONTRACTOR'S DECLARATION
[herebyaBum 7000).DIv arn licensed under erprovisions ofeadoner9(commenc- APPLIANCES-RESIDENTIAL - JOB DUbCxIImUN
It ..i inf.H7006)ofDivltlon3 o(the Buslneasand Pro(esslonsC-cads,and my - l^,J^ "y"Y"-q]Cp--', ,
Li.. Is In(uLL form and effect. PANELS
Liate Clam C_s j,k.X
Date 61—ISI-41 Contnc
/
ARCHITECT'Shallbeused
as public
OVERDO AMPSw.�.a.a/SQ..F
��qqvv 0❑Q Iunderetand my pisco shall be used sspubOc records. OVER 1060 AMPS SQ.FC.FLOOR AREA S/SQ.FT.
k tj Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCEiCUIT/M6C
y � I herebyaffirm that I am exempt fromthe Contractor's License Law forthe
Q qqqq following reason.(Section 7031.5,Business and Professions Code:An d or
OR-
county which requires a permit to mretrud,alter,improve,demolish,or repair TEMIa'MEf7I20R POLE INST.
qEO any structure prior to its issuance,also requires the applicant for such permit to
PJ rwE file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
036 O Contractor's Lice.Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING ELECTRIC
-sion3ofthe Butlnessand ProfesstoruCode)orthatheisewmpttherefmmand - VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OIITLET'SSWH'CF3FSFIXTURES
G applicantfora permit subjects the applicant to a civil pemlty of not morethan
$
Eve hundred nodus he pr. NEW RESIDENTIAL ELECTR FT, STORIES TYPE CONSTRUCTION
�n rnp as owner of the property,or my employees with wages r there sole
compensation,Bwill do..irstheworkandthe ions Code: is not oroffered for
O
Is(Sec.apply
to aniowix,and f property
Code:The or Imp owes License Law _
$
does not apply toanownerofpropertywhom em orcesprovithereory and OCGGROUP RES.UNITS
EE whodoeasuts are not
tIntededorough hbowne.If,hoeeer,theuilding ou
Improvementsared within one earofod(peals.I(,however,theTOTAL:
Improvement bwld wllhin oneyearo(completlorytheawner-6ullderw111 have
9M.Ilarden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
u S as owner of the property,am exclusively contracting with licensed ` PERMITISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such projects with a
cuu(s)licensed pureuant to the Contractors License Law. BAIX FLOW PROTECT.DEVICE
SUMMARY
LJ oli,Am exempt under Sec. B&P C for this reason
Owner ate
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y - N
- - DRECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI{OOL TAX Y_ N
h af(Irm that I have a certlBcate of conaent,to uB-Insure,ora RECEIPT M
certiftcate o(Worken'CamperuaHon lruurana oracerti(kd copythereo((Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
RECE3800,Lab C.)' po
Poll X bJ PT
GAS EA.SYSTEh1-OVER•. Com nv � BUILDDINGING DIVISION FEES
Cemfied copy b hereby
I�CerHfied copy b filed withh the city the inspection division.d. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
'
S'� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER SANITARY STORM EA 2001717. Date Recel [#
(This section need not be completed lithe permit is forom hundred dollars
(5100)orfy that
W4M HEATER W/VENT/ELECTR �pp� ENERGY FEE Y N
I certify employ
any person inhe aof ny
unser so is to becomis e
esubjec booed, I •vJIJ
I shall not employ any lemon In any manner m m to become subject to the WATER SYSTEM/TREATING
Workere'Compenmtlon Laws of CaB(amia.--Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.Ff.' Date Remi t#
O NOTICE TO APPLICANT:If,after making this Certificate o(Exemptiory you
F should become subject to the Workaa'Comperuatlon pmvisiomo(the Labor +TOTAL:
9 Code,you=at forthwith comply with such provisions or this permit be BUILDING E
W > deemed revoked.
(L CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby.M that there b a construction lendingagency for the perform TOTAL: a.�T� ELECTRIC FEE '
( Z once of work for whkhthb per beued(Sec.3097,Civ.Cd �-lJ PLUMBING FEE
,) O Lender's Name
LL F Lender'.Addm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE a i
OW- I.difythatltovereadthbapphmtlonandstatethattheaboveinformatton
ll iscomot.I agree to complywith all dtyand county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this
zcity to enter upon the.bove-mentioned property for inspection purpose.. ALTER OR ADD TO MECH. Date R2Cel t#
— (We)agree to save,Indemrdfy an d keep harmless the City of Cu pertlno
against liabilities,judgments,cosbsand expenses which may to anywayaocrue AIR HANDLING UNIT CID 10,W CFM) SUBTOTAL'
against said City In consequence of the granting of this permit..
C , A —,14 AIR IuhrouNc UNIT(OVER 10,000 CENT) CONSTRUCTION TAX
Signature Signature n�cant%CoofiNelI Date EXHAUSTmol)(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,060 BT[]) Date ReCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
I k❑alth and Safety Cad er ctton 25532(a)7 HEATING UNIT(OVER 100,006 BTU) TOTAL: NA-cin
EaY. I�No
Ill theapplicanta re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSU1949%dkTE
which emit hazardous air comaminant.as de0ned by the Bay Area Air
(iLality Managementl) d7 BOILER-COMP CHIP OR 100,000 BTU)
4 Yca o y J
haverHealth
oet materials 1..25505, under 25533 and
of BOILER-COMP(OVER 100,OfA BTU)
the und ertanCaliforniank Health&building
Code,Sections 75505,25533 and 25534,I -
respoxanlitytod that f Ifyhe the occupant not errently equire ave encs which
that It meta my NEW RESIDENTIAL MECH. SIFT
r riot to Iss anc not fa Certificate
i occupant of Occupancy.requirements which rwst be met
' prior to Issuance ofa Certiflate of Occupanry.
'Owner or authorized.gen �e B .
TOTAL: ISS
OFFICE COPY