21823 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
❑❑ BuildingPw'ect Identification PERMIT NO.
d.
Building
�r fi-NTN Die . Q - 21823
V6�'A
/a f—Ce-lo ( T 973-/00 CITY OF CUPERTINO-BUILDINGDIVISION A A
Con
sNajrc� F— r/Yv6 k. APPLICATION I PERMIT �'8 —��
BUILDINC-ELECTRICAL-MUMBINGMECIIAMCAL CATEGORY CONTROLN
Arngineer. Lie.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S D.CIARATION
I hereby affirm that lam licensed underp laIons of Chapter 9(commeno- APPLIANCESRFSIDENTIAL JOB DFSCRIUCIN
ingwith SecBoa700Eof Divlslon3 ofthe Busl asand PrefesslonsCode,and my
lice aseislnfullfxemandeffed. PANELS ��jj FT��.� .a-..��
License Class Lic.N Fv(Wrpws_9
Dale Contractor
ARCHITECT'S DECIARATION ZOt-1000AMP5
Q2 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ZCO
(/ Licensed Professions) ISIGNS ELECTRICAL
<m OWNER-BUILDER DECLARATION
In a SI'ECIALCDiCUIT/M15C
7 I"vl I hereby affirm that f am exempt from the Contractor's sundae law for the
following reason.(Section 7031.5,Business and Professlom Code:Any city or
F., TEMP.METER ORIOLE]NST.
countyanystm hkhrequkesaper me,aL requ a)theapbuntfmwch, er ttr
any atsigned statement
that
the I,lire mgWmsuant t the nwialhpeof t e IOWF.R DEVILS
K fileCo a signed scene eLa that he t licensed pursuant it the proalIons of the
p� Contractor'sugueeLaw(CIf 9(comrrendn with xemp"herefof Divi- VALUATION
(Chapter B sv SWIMMING IDOL ELECTRIC
O< slon3ofthe Buslnessand ProfeslonsCode)orthar helaexem Iherefromand
Q Q S the basis for the alleged exemption. Any violation of Section 70315 by any OU UETSSWITCHESFTK TURES
applicant for a permit subjects the applicant tea civil penalty of not more than
$ five hundred della.($500). NEW RESIDENTIAL ELECTR SQ. . STORIES TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sole
7Qcompensait " Uldo the work andthestructure Is nm Intended or offered for
sale(Sec.7004,Business and Profemlons Code:The Contraciofe License law
$ does not apply to an owner ofproperty who Wilds or improves thereon,and OCC.GROUP RIS.UNITS
who does such work himself orthrough his own employ.,provided that such
impmvemenN are not Intended oroffered for sale.If,however,the W Ilding or TOTAL:
improvementhisold within oneyearofeompletion,lhe owner-bullderwill have
the_�irden of proving that he did nes build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Conmetor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such pp"with a ALTER-DRAIN -WATER(EA)
,�fa&eels)Bcensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under See. B k P C for this reasonOUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIT'p
WORKMAN COMPENSATION DECLARATION FDCTURES PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a redlRnte of consent to eel(-insure,or RECEIPT 0
certificate of Worke.'Corepensatlonlosurance ora certified copythereof(Sec. GAS EA.SYSfFM-]INC.40UILEIS PARK FTE Y N
3800,Isis C.I s a 1(—s !ICL?Z RECEIPT#
Policy W _ 7 T GAS FA.SYSTEM-OVER4(EA) BUI LINING DI VISION FEES
'DOtCCom anv
rtiBed copy is heed with the cit. CREASE/INDUgML WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CRE'ASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WITF. Date RCCCI t#
(Thlssection need net be completed ifthe permit is for one hundr l dollars
(Ellie)°'les°') WATER HEATER W/vFt-rl'/F7,ECTR ENERGY FEE Y_ N_
1 certifythat In the performance of the work forwhich this permit Is d
bsm ,
1 shall not employ any person in any manner so as to become subject to the WA.f.FRSYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,You
N should become subject to the Worker'Compensat ion provisions of the Labor TOTAL:
Cod,you most forthwith comply with such provisions or this permits hall be BUILDING
W _ deemed revoked.
CONSTRUCTION Is sons LEVUdO AGENCY SEISMIC FEE
CL ]herebyaffirm trahkhtlaacomtIs tion IssudSer. agency 7,Cio. .) peAorm- TOTAL: ELECTRIC FEE
Z Lender. work forwhkhthla permit Is Issued(Sec.?09J,CIv.C.) PLUMBING FEE
(� O lender's Name TY. MECHANICAL PERMIT FEE
LL H Urider'saddmaa Q MECHANICAL FEE �.a
U Icedlfythatl have readthisapplimtlonand satethat theabove Information
O W lacomet.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE 1-2...60 FEES PAID:
} (L relating rebuilding construction,and hereby authorize representativesor this
Zcity to enter upon the abovimenthmed property for inspection purposes. ALTER OR ADD TO MF:CH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
0 against liabilities,Iadgem ts,cossand expereat which may in any wayaceme ATR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
agLinsrsaid Cl In anpuenre of the granting of this pc
Z ARHANDL NG UNIT OVER tO,ODOCFM) CONSTRUCTION TAX
ignsmre of Appllcant/Contractor Data E)(HAUSTHOOD(W/DUZT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE Ca
Will the applicant or future building occupant store or handle hazardous FiFATING UMT(T0100,f1006TU) La.C7C7 Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the - s'
Heahh and Safety Code Section 755370)7 HE ATWG UNIT(OVER Fall,"BTU) TOTAL: 4100
❑Yes M No �i#
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANRrMOTE
which emit hamidous air conramins nts as dented by the Bay Area Air �
• Quality Management District? BOILFR-COMP OFT'OR 100,000 BTU)
4Yee nn No ��--
havereadthe hazer�eusmaterials requirements under Cha pter6.95 of BOILER-COMP(OVPR100,0000TU)
the Czlifomu at if the
b Safety Code,Sealons 25505,25533 cswand 75534.]
undersrandts Health
Ne building does rant arentlynd2553that lrbmy NEW RESIDENTIAL MECH. SQFI
responsibility to notify the occupant of the requlrementa which most be met
priorto issuance of a Certificate of Occupancy. �y�
Owner or authorized agent Date TOTAL: 21,E ISSUEDBYyk--a0"%
OFFICE COPY