21769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIIRMITNO.
Building Addmss: o 21769
2 l�� c�
r- wnera sate: r y. A A
CITY OF CUPERTINO-BUILDING DIVISION r � �
tranora Name: LIT.No: APPLICATION / PERMIT
G IN Is BUILDINGELECTRICAL PLUMBING-MECHAMCAL CATEGORY CONTROL N
is /Engineer. Lie.Na:
QTY ELECTRIC PERMIT FEE BUILDINGPERMIT INFO
Address: I PERMITISSUANCE ® I ;K ❑
LICENSED CONTRACTOR'S DECLARATION �`
I herebySectio 7000)tlam licensed under eBusinmandprovisions offesk=sChapter 9de,and c- APPUANCESRESIDEMTAL JOB DFSCRMION
Ingwlth51 Nu f00J)o(d effeon3o(the Bualnessandl'roleeslona Code,and my
If ana is In fuBf and effect. PANELS
Llanx Clan _ Uc.N' o L 7
ate I 1 1 Contractor LIP TO 2DO AM
ARCHITEGE'SDECLARATION 201-100 AMPS
O] I understand my place shag be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
u�O Licensed I'mfenbwl
F SIGNS ELECTRICAL
tG Z
G 6 ul OWNER-BUILDER DECLARATION
In� SI'FGIALCDtCU1T/MLSC
Ihercby a(Bnn that[cam exempt from the Contractor's License nLaw fm the
Zt..,p following reason.(Section 701.5,Business and Professions Code:Any city or
KZt"'u9 county which requirma pernettocoretruct,alter,improve,demolbh,or repair TEMP.METER ORPOLE INSC.
$m�m '.� any.tsinure t.temoit.bat he 1,also sed Pursuant t the provision of t e POWER DEVICES
E K � file a signed statement that he b licensed Pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 700)of Divi- SWVALUATION
iii���30�n elon3oflhe Boniness and Profenloa Code)orthat hebexmpteherefromanSWIMMING POOL ELECTRIC �.a
b< the basis for the alleged exemption. Any violation of Section 7015 by any OUTLETSSWITCHESFIXIURV
ES I L Q0 O ...ate
applicant for a permit subjectstheapplicant to a civil penalty of not more than C
R O five hundred dollars($500).
L ELECTR �.Fr.
F1 1,I,.s owner of the property,or my employewith wags as there sole NEW RESIDENTIASTORIES TYPECONSIRUCTION
compensation,7 44,Bulini wilichothe work andthe structure b not Intended or offered for
O vie(Sec 7004,Bushiesa and Pro(essloa Code:The Comractul.Llanse Law
don not apply to an owner of property who builds or lmprovn thereon,and OCC.GROUP RES.UNITS
F. whodoessuchworkhbrselforthrough hlsownemployces,provided thatsuch �1
Improvements are not Intended oroffered for sale.Hhowever,thebuildingoe TOT L1,SO
Improvement b aold within oneyearofcompletlon,the owner-bullderwlll have
tlAlZarden of proving that he did not build or Improve for purpose of aale.). QTY. PLUMBINGPERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with Ilrensed PERMIT ISSUANCE
contractors to construct the project(See.7oWq Business and Professions Code: Zc
'Iba Contractor's License Law does not apply to an owner of property who ALTER-DRAIN Ar VENT-WATER([A)
Wilds or improve. thereon, and who contracts for such ptojens with a FEE SUMMARY
�gWfanor(a)licensed pursuant to the Contractor's License Law. BAIX FLOW PRl7fECT.DEVICE
L�I am exempt under Sec. B k P C for this re FLES
vncr Date DRAINS.FLOORROOF,AREA,COND. SANITARY Y N_
RECEIPT N
/ WORKMANCOMPENSATION DECLARATION �fJ1. co SCHOOL TAX Y_ N_
1 hereby affirm that I have a cerifiate of consent to self-Inure,or a FIXTURES.PER TRAP _la RFLEIIaf N
certificate of Workers Compenuation Insurance or a certifbd copy thereef(Sec. GAS FA.SYSTEM-1 INC4 OLTLM PARK FEE Y N
MM,Lab C.)
RECEIPT N
policy N
cCAS EA.SYSfEM-OVER 4(EA) BUILDING DI VISION FEES
C.
y
ManIfled copy fs hereby fumbhed. GREASE/INDUSIRL WASTE IMIIKEPTOR PLANCHECK FEE
Certified copy Is filed with the city Inspection division.
CERTIHCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20aFT. Datc RCCCI t7i
(fhb srction need not be completed If the permit b far one hundred dollars
(SI0)mlen.) WATER HEATF]i W/VEM/dECTR ENERGY FEE Y_ N
a _
I certify that In the performnce of the work forwhich this permit Is issued,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Ca Rfomla.Date PAID
O Z ApplicantNEW RESIDENTIAL PLMB. SQFr. Date Recef ted
Z O NOTICE TO APPLICANT:ILafter ma king this Certificate of Exemption,you
PW should become subject to the Workers''Compeceatlon provisions ofthe Labor TOTAL:
K Code,you=atforthwith comply with such provisions or this permit shall be BUILDING FEEUO
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 50
d Iherebyafflmtthat there be conatmeron lendingagency forthe perform TOTAL: ELECTRIC FEE
!
Z the work for which this permit bbrved(Sec.3097,Civ.C.)
V Lender
s� PLUMBING FEE bc�
O lender's Nacre TY. MECHANICAL PERMIT FEE
IL f Lender'.Addre.. Q rmMECHANICAL FEE
OW I cortifythat l have read this application and Rate thatthe above Information
S iscormet.l agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. (L ng to building comructlon,and hereby authotl c representatives of this
F N city to enter upon the above-mentioned property for lrepMion purposes. ALTTRORADDTOMFGH.
Z (Wr)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,Judgments,costa and expenses which may in anywayacccue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in con equene,of the granting of this permit.
P ` �/n AIR HANDLING UNIT(OVER 10,00CFM) CONSTRUCTION TAX
g tum of Ap J!C 1rrAn1—corm- / D'—A EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAL RDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(T010,00 BTU) Date Recei tlf
material a defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iicalthand Srfny Code Sect1on25532(a)? HEATING UNIT(OVER IDQ000 BT13) TOTAL:
MYes n No
Wllltheapplicant or future building occupant use equipment ordevicn VENIILATIONFAN(5INGLERFSID) ISSUANCE DATE
w IcheMllavr ousalrcontaMnantsasdefined bytbe Bay Area Alr
go lity Mewgemcnt District? BOILER-COMP OEB'OR 100,00 BTU)
WYeaNP.o
S ave madthehazar o matedab requirements under Chapter 6.95 of BOILER-COMP(OVER 10,00 BTU)
the Cahfurala i lealth k Safety Code,Sections 25505,25533 and 25534. i - 1npl O as �(1r17
undersand that ifthebuildingd.n mmrmnllyhaveatenant.tlat itbmy NEW RESIDENTIAL MECH. SQ.FT .JAN W Y .7s71
rapoalbility to not[fy the occupant of the requlremenls which rtwst be mart
prior to Issuance of a Certificate of Occupancy.
Owner or authorized TOTAL:agent Date ISSUED BY:-
OFFICE COPY