21033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ert Identification PERMIT NO.
B.9ding Address: 21033
796 .1-11- Y Cr C i ' c . a
wnero sere:
C 5 YCO '15M—_Aw+ " CITY OF CUPERTINO-BUILDING DIVISION
r or6L�l3 APPLICATION / PERMIT
bCto BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CON'f�F1L/� (�
Architect/Engineer. _ Lk.Na: - V- C,� �+
QrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - s��r �
LICENSED CONTRACTOR'S DECLARATION PERMIT ISSUANCE X.JL� . ®' y .JF] D
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCESRESIDENERAL JOB DESCRJTMON
Ingwith Section 7008 of Division 3 olthe Buslnessand PrpjkWm.C,.ode,and my
license is in full force and effect. PANELS �t�J
Licensef}aqs�Lk.B a'C a0 L-,1
Dare /_yJ Contractor. -
e r/A�CHaDbeus DECLARATION 201.1 OVERI0 AMPS
1011
�Z I undentand my plain shag be used u pubOc records OVER 1(M76 AMPS �,FC.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL ,
6 OWNER-BUILDER DECLARATION
fn I SPECIAL CIRCUIT/M15C
k., owing affirmthatIam31.5,Business exempt ed Professr'sLlrense Gw fw the Z Ofountywreason.iSectionrmi1.5,Bustruc and Professions Code:Any tltyor
ir
02-H� TEMP.METEROR POLE[NST.,
� rountywhich requUesapermleta mnstruR;alter,Improve,demolbh,orrepair
44� .i1i anystruclure priorto its issuance,alsorequlrestheapplicantfor such permitto POWER DEVICES
(� file a signed statement that he is licensed pursuant to the provisions of the
tt
Contractor,License Lw(Chapter 9(commencing with Section 7000).f Divi-
�OQ sion3 ofthe Busineasand PiefemmnsCode)orthat he is exempttherefamand SWIMMING POOL ELECTRIC / ,tet VALUA'f}0tys� ,
Q.�a the bas's for the alleged exemption. Any violation of Section a 70315 re any OU7LE•S-SINTWHIESFIXTURES '{`,'Jf
Ao app hundrfora onors $500).subjects the applicant toativii penalty of not rtnrethan
five hundred dollen($500). NEW RESIDENTIAL ELECTR roSQ.FC
�m �I,as owner of the property,or my,employees with wages as their sole .STORIES TYPE CONSTRUCTION
nempensatlon,wfildo the work and thestructure Is not Intended or offered for
psale(Sec.7044,Business and Profession's Code:The ContraRot•License Lw
$ does net apply to an owner of property who builds or improves thereon,and
who doessuch work himself or through hisown employees,provided that such OCC.GROUP, RES.UNITS
Improvements are not intended or offered for sale.l4 however,the building or TOTAL:
Improvement Is sold within one yearofcomplelion,the owner-bullderwlll have
tl)akurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ^�
contractors to construct the pmject(Sec.7614 Business and Professions Code:
The Contractor's Lkerue.Law does not apply to an owner of property who ALTER-DRAIN k VIM' WATER(EA)
Wilds or improves thereon, and who contracts for such ptojects with a ,FEE SUMMARY
w optpctorW licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec.' B h P C for this reason
CUTS I DE FEES
Owner oth S
DRAINFLOOR ROOF,AREA,COND. 'zs� SANITARY Y N
DRECEIPT N
WORKMAN COMPENSATION DECLARATION p1XTURES PER TRM SCHOOL TqX Y N
❑I hereby affirm that I have a certificate of consent to self-insure,ore Rte,M
certificate o(Wurken'CwnpensatlonInsurana ora certilled copytherrof(Sec. 1
3800,Lb CJ GAS EA.SYSTEM-1 INCA OUTLETS � PARK FEE Y N
l
irryp GAS EA.SYSTEM-0VER 4(EA) RECEIPT p
CoMy BUILDING DIVISION FEES
Certlfled copy 6 herebyth the cityad. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEB
�Certl(led copy V(fled with the tlty Inspection division. � o
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP • PAID 1-f�o'
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA I(0FT Date Revel t# LO0.G9
(This section need not be completed lithe permit isforme hundred dollars
($100)or less') WATER HEATER W/VENT/E,FCTA ENERGY FEE Y - N
I certify that In the performance of the work for which this permit is issued, —
I shall not employ any pemon in any manner so as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation Laws of California.Date PAID
O Z AppNOTICE
shoulNEW RESIDENTIALPLMB. FI. Date
NOTICETO become subject
aftermakingthissationcaleof Exemption,you c'Q
(7 Code, ou War
forth ithto co plywit Compensationprovisions,
orthimuomite Labor O.
deemreninksreanwmn comply with such provisions or this permit shall he BUILDING FEE
W D deemed revoked.
a c CONSTRUCTION LENDING AGENCY. SEISMIC FEE'
I hereby affirmthat there V a rosutmRlon lending agency for the perform- ELECTRIC FEE
Z once of the work for which this permit is issued(See.3097,Civ.C.) TOTAL: s�
L) O Lnder'sName PLUMBING FEE
, LenderaAddreas QTY. MECHANICAL PERMIT FEE `
LL �
O W IcerHfythatl havereadthis application and statethattheabovelnformatid' MECHANICAL FEE
bcortect.I agreeto complywith all dty and county ordinances and state laws PERMTTISSUANCE FEES PAID;
Nrelating to building construction,and hereby author ice mprexntatives ofthis
Z city We upon the above-menlloned property for Inspection purposes. ALTER OR ADD TO MECH. Date Recei t#
ee to save,in a d keep harmless the City of Cupertino P
A Abilities, dg is, s d expenses which maylnanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a tsaid Cltyin mnequ granthgofthispermit. -
AIR HANDLING UNIT(OVERIO,ODOCIRN) CONSTRUCTION TAX
nature of Applicant/ or Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX-PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulurs building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ROCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes I]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
pIu�—a1litit_y Management District? BOILER-COMP OTE'OR 100,00)BTU) It@.FtlRrss`t
✓ ZYrs rd No �LL/FP'�.O
vemad the haza ousmatdd,l al..255nlsunder Chapter.I of BOILER-COMP(OVER 103,000 BTU)
! the Gltand t Health k Safety Code,Sections 75505,have
a t and 25534.I -�7^ o �IRQV
undentandthatlithe building does not currently have atenanL that itbmy NEW RESIDENTIAL MECH. �,FT. t.I Lti $? 1:3M�y
responsibility to notify the occupant of the requirements which At be met
prior to Issuance of a Certificate of Om pa ncy. _
Owner or•utherized a gent Date
TOTAL: ISSUED 8Y: 't✓`i�1)J N�/ L
OFFICE COPY