21370 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification P13MT NO.
Build lag/ddmes7/ �L e f� 2 21370
um
cors ams: one: -
-70 U G -� CITY OF CUPERTINO-BUILDING DIVISION O
Co 'sr1110ntracture Name: Lk.N. APPLICATION /PERMIT 1
.v Y
BUILDING-ELECTRICAL MtJMBING-MECHAMCAL CATEGORY CONTROL
•�,
AuchRectlEngireen - Lt.No:
�TA /� QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Add.. G✓77�/A/� UiS (N . PER)ATISSUANCE �- � El-
1
CONTRACTOR'S DECLARATION
(hereby affirm that l am licensed under provisions of Chapter 9(conamrst, APPOANCESRESIDENTIAL JOB DESCRIPTIONIngwith Sediun70DD)of Dlvlslan3ofthe Buknnsa dPmfessionsCodgandmy
Bronx Isla tuB( effect PANELS
Licenx Class /r L,.LIff c Y7-41Y5
J JI
Date Contractor UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-IODO AMPS
�+p+,
9077 I understand my plans shall be used n public records. OVERIODOAMPS SQ.FT.FLOORAREA S/SQ.FT.
k�U Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
ZF- Iherebya(Ormthatlamnemptlromthe Cont ranors License Lew forth.
O following reason.(Section 70315,Business and Professions Code:Any city or -
Z F. TCMP,METER OR POLE(NST.
county requimaa Lpermit sue.c,coi.requalter,Improve,amfor. eh,orrepair
file.signed Stan mot that he Is aha sed pursuant
tos such permitro
file a signed statement that he V licensed pursuant to the provisions of the TOWER DEVICES
O u, Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvl-
30({� alon3ofthe Budnessand Prd(nsslom Code)orthathebeumpithemfromand SWPIMING IDOL ELECTRIC VALUATION
G the bash for the alleged exemption. Any violation of Stolon 70115 by any O1ITLETS-SWITCHES - Q DG
applicant fare permit subjects the applicant to•civil penalty of rot morethan _(����
Ov�undred dollars(SM. NBwRI$TD LE
QQQ 1,as owner of the pmperty,or my employees wages as their sole STORIES TYPE CONSTRUCTION
7Q compensation,will do the work and the structure be not Intended or offered for
xle(Se.7014,Bualnne and Pmfesslons Code:The Contractors License,Law
r3$ does not apply to an owner of property who builds or lmpro+n thenars and JOCC.CROIJP RFS.UNITS
EEEEEE who doessuchwork hlmxlforthrough hlsomempioyces,provided lhatucA
Improvements are not Intended oroffered for sale.It however,lhebulldlngor TOTAL:
Improvement Issold withlnomyearofcompletlon,theowner-bu0derwillhave
thAkurden of proving that he did not build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD TONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMTf ISSIIANCB
contractors to construct the project(Sec.7074 Business and Professions Code:
The Contractor'.License Law docs not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EIV
builds or Improves thereon,and who contracts for such psojecta with a
coytradarts)licensed pursuant to the Contnnors Llrenx Law. FEE SUMMARY
LJ I am exempt under See B k P C for this reason BACK FLOW PROTECT.DEVICE
narru.run.!R
DRAINS FLOOR ROOP,AREA,COND. SANITARY Y N
. Owner Data RECEIPT Y
WORKMAN COMPENSATION DECLARATION FO(IURES-PER TRAP SCI300L TA% Y N
❑I hereby affirm that I have o certificate of consent to pythemf ora RECEIPT Y
3800,La a Cf Workers'Compensatlanlnaunnceora cenlfled ropythereof(sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FTE Y_ N
Policy
Isis C.)
Polley p RECGAS EA.SYSTFM-OVER 4(EA) DING DI M
Com env T— BUILDING DIVISION FEES
[fCenln copybhereby(umi ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
''[[��P"'arllled copy is filed with the city inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP ppfp
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 200FT Date RCOeI t#
(This ionneednmbecompletedifthepermitleforomhundreddollars
(5100)or Ices.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certifythat In the performance of the work forwhich this permit la Israed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/1REATING
Workers'Compensation Laws of California. Date PAID
O Z Applicant
NOTICE
Z O NOAPPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recef t#
F W should became subject to the Workers'Compensation provisions of the Labor TOTAL:
S. Code,you must forthwith comply with such provisions or this permit shall be
> deemed revoked. BUILDING ECE
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby afRrmlhat there Is a consUuctlon lending agency forthe perform ELECTRIC FEE
7 Z ante of the work for which this permit bu
Issued(Sec.3097,Civ.C.) TOTAL:
V O Leaders Name PLUMBING FEE
LL H Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW (certify thatl have read thbapplicatimand statethattheabove ln(omutlon
C Iscomad.7 agreeto complywlth all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
(_ city to enter upon the abovementionad property for impaction purposes. ALTER OR ADDTO MECH.
Z Date Recel t#
— (We)agree to save,indemnify as d keep harmless the City of Cupertino
aga1nst11abjIlea,judgmrt
ents,cases and expenses which may In anyway..e MR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalmisaloCC inconsequence the gra Ungof thlepertmi.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
an o•_4AP n or �t O allAUST HOOD(W/DUCp CONSTRUCTION TAX PAID:
F1 US MATERIALS DISCLOSURE
Wia the .fin lathe future buildingOccupantlode, hapten lehazsrdow HEATING UNIT(10 100,00D BTU) Date Rece' t#
material as defined by the Cupertino Municipal Code Chapter 9.12,and the
HealtYeMSafety CodiSeNo
q25532(x)7 HEATING UMT(OVER 100,00)BTN TOTAL: CP
Rl the applicant or❑future building ompant use equipment ordevices VEN LA71ON FAN(SINGLE RESID) IS DATE
which emit hazardous air contamlmnls as defined by the Bay Area Air
. Quality Management District? BOIfER-COMP OFB'DR 100,000 BTU)
Y. 9❑No (4
ave read the hazardom materials requirements underChap(er 6.95 of BOILER-COMP(Ova100,00)BTU) rt;
the CalBonia Health k Safety Code,Sections 25505,25533 and 15534.I { JU90
understand that If the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FL n
rnpamlbilitytonatifytheompanto(the rsqulmmentswhkh must berM 'y x6d __,y. aale�
prior to issuanm of a Certificate of Occupancy.
Owner or aulhorixed agent Data TOTAL: ISSUFDBY:
OFFICE COPY
I