21946 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Idendflcati.n PERMIT NO.
Building Address: t 4l n 21946
wners aces, one: APPLICATION SUBMI I IALA
14
CITY OF CUPERTINO-BUILDING DIVISION
Cmu,acua, Lic.N.: APPLICATION /PERMIT T \ l
CP-'3 BUILDINGa2CTRICALPLUMBIN'G-MECHANICAL CATEGORY CONTROL N
rrhhxn/Engineer. Lie NO
QTY ,"s , 'ELECTRIC PERMIT _ FEE BUILDING PERMIT.INFO
SL Q.M Is
Address PERMIT ISSUANCE ❑ 1:1 E:1LICENS EO CONTRACTOR'S DECLARATION
I hereby affirm that lam Bcenaed under provialonaolChaptei9(commmc APPI3ANCESRESIDENTAL JOB DESCRIPTION
ingwith Sectmn 7(100).(Dlvtsion3ofths Busirsssand Profnsio..Code,and my
license is in full fo
rce and d(ect. PANELS
oCI �L�0d.r�-t2fQ { N—
ARCHECPSDECLARATION MI-1000AMPS
IT
qqq ntzI understand my plans shall be used as public mvrds. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Op
0 Licensed Professional
SIGNS ELECTRICAL NWLED IN
OidEOWNER-BUILDER DECLARATION SPECIALCERCUIT/M1SC
Dian-
r; bIherebyafRrm that l am exempt learn the Contractor's License law for the DUT
pp ? following reason.Rection 7015,Business and Profevmns Code:My city or TyMW
P,METERORPOLEST.
_ coontywhtchrequvesa permit to mratmct,alter,Improve,demolbh,.rrepair
I`S a�Cei anystructure prior to its issuance,also requires theapplicant forsuch permit to )-OWER DEVICES TE V I'
r ❑
^V file a signed statement that he b Bcensed pursuant it the tion.)of the
%O,. Can3o(thUcen Lawand rofmer9(mmmendathe6 Sectionhem)of Divi- SWIMMING POOL ELECI7UC
sian3o(the Buvnessand ProfessianaCede)orthat FebexempHherefromand VALUATION
-y^ the basis for the alleged exemption. Any violation of Section 7WIS by any OUTLETSSWITCHFSFIXTURFS
%�� applicant for a permit subjects the applicant to a civil penalty d not more than
_ five hundred dolWs(S5m). NEW RESIDENTIAL ELECTS SQ.FT. STORIES TYPECONSIRUCTION
I,a owner of the property,or my employees with wages as their sok
Cc6 compewtion,wBldothe work,and thestructom is not intended or offered for
p sale Ree.7044,Rushers and Profession Code:The Contractors Lianas law
dp $ does not apply to an owner of property who Wilds or impewn thereon,and OCC.GROUP RES.UNITS
c-5^ who does such work himself orthmugh Me own employees,provided that such
Improvements are not Intended or offered fee sale.If,however,the building or TOTAL:
Improvement issold within oreyearofcomplen on,the owner-budderwill have c
Tylyden of proving that he did not bund or impmve for purpose of sale.). QTY. PLUMBING PERMIT " ' FEE FLOOD IDNE APN
Ll I,as Owner of the property,am exclusively mntrac Ing with licensed PERMIT ISSUANCE
cancan..to construct the pmjeat(Sec.7014,Suit..and Professions Code:
its Contractors License law don not apply to an owner of property,who ALTER-DMIN&VEM-WATER IRA)
Wilds or improves thereon,and who contracts fee such p\ujects with a '•+FEE SUMMARY +' •;.
coctor(s)Ikensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE
L-11 am exempt undo Sec B&P C for this reason
DRAINS A,FLOOR,ROOF,ARECON I. SANITARY Y_ N_
Owner Date RECEIPT N
WC."AN COMPENSATION DECLARATION H)(TLIRES PER TRAP SCHOOL TAX Y_ N—
MI hereby affirm that I have a cer<f0ote of consent to self-Insure,or a RECEIPT a
:ertifiam.1workers Compovottion Wumm Or.certlfkd copy therexaHsce. GAS FA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N
3Sm,Lab C.) BECEII'T N
Policy 0 GAS F.A.SYSTEM-OVER d(FA) BUILDING DIVISION FEES
an
n Ned copy is hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHGCK FEE
�Ceridied copy b filed with the city Isapection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.POET, Date RCCeI [#
(This section need not be completed lfthe permit lsfor one hundred dollars
(Slm)orless.) WATER HEATER W/VENT/ET )= ENERGYFEE Y_ N—
I certify that N the perfornanm of the work for which this permit Is taxed,
I shall not employ any person in any manner so as to become subject t.the WATER SYSTEM/TREATING PAID
Workers Compensation Laws of California.Date
O Applicant NEW RE31DFNTIAL PLMB. SQFT. Dale Remi t#
Z Z NOTICETO APPLICANT.If.afterki
mangthis Ccrtificateof Exenufmon,yau
0 sheaddbemmesubjecttothe Warken'CompmaUonprovisiomoflhe Labor TOTAL:
m Code,you must forthwith comply with such pmv9iam orthis permit shall be BUILDING FEE
darned revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L O I hembyafBrmthat there is a construction lendinperform TOTAL:
forthe perfoTOTAL: ELECTRIC FEE
ID Z anceoftheworkforwhlchthbpermit is,Wued(See 3097,CIv.C.) PLUMBING FEE
() O Lenders N. QTy. .',j. MECHANICAL PERMIT, FEE
LL F Lender.Addreas MECHANICAL FEE
O w 1cedifythatIhave mad thisappllntionandnatethattheabove information
l PERMIT 2= FEES PAID:
d 6correct.l.gree to comply wfthall city and munty.rdinanms and state laws aa��--��
} W relating to building construction,and hereby authorlae representation of this ALTERORADDTOMECH. x o
E- Z city to enter upon the abovo-mentioned property for inspection purpose. ' Date Receipt#
V _ (Wc)agree m save,indemnify and keep harmless the City of Cupertino AIRHAINDUNG UNIT CTO 10,000 CFM) SUBTOTAL:
against liabilities,pdgments,cons and expenses which may litany way..-
gaWts in Cconl race.(the gr.�m/y-gofu permit. T� AIR HANDLING UNIT OVER l0,000CFM) CONSTRUCTION TAX
�eP�U�� ` CONSTRUCTION TAX PAID:
S' sum (Applicant/Contranor Date \ IXHALST FLOOD(w/DIXT)
HAIIARDOUSMATERIAL DISCLOSURE HEATING UMT(TO 1m,0000TW
Wllltheappliaut or future building occupant stare or handle hazard.., *Fr Datematerialasdefined by the Cupertino Municipal Code,Chapter 9.17,and the
Hmlthand SfetyCde.Section75537(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:� YeVENTLATION FAN SINGLE RFSIDI ISSUANCE DATE
Will the appllant.r(umre building omspamuseequipmentordevice which emit havrd.us air cont.Mnants as defl red by the Day Area Air BOILER-COMP OE IP OR 100,00 BTU)Quality Maiagerrent District?
4 Yea I INoBOILER-COMP(OVER IKOW BTU)have readthehav ous rvtedab requirements under Cfiapter 6.95 of the Calif.rnu Health&SrfetyCode,Smions 25505,25533 and 25534.1 yy RESIDFNLTAL MECH. v
M
that if the building does not currently have a tenant,that it u my
ruiponsibility,to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
H s
Ow.c,.r avth.rizsd agent DaOe TOTAL: ISSUED BY'
OFFICE COPY