21337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proec Identification PERMIT NO.
Build i(gO1rei:I Mtier PL ass 160 21337
Zne9 /' one: A
"� �k J P-WI 1)A,—l s CITY OF CUPERTINC-BUILDING DIVISION
Can�(rector's Name: - 1 J LIc.No: APPLICATION I PERMIT
S'T'eV�ry �hCf'CGIAI��`lTt-�nGe� LS BUIL
a� DING-ELECTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROLX
-� Architect/Engbser. LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ( Q� I'� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �J
I hereby affirm that l am licensed under provisions of Chapter9(cemmen APPLIANCESRESIDENTIAL ]OB DESCRIPTION
Ingwlth5eci/on70(D)o(Dlvlelon3o(theguelneeeand ProfessionsCode,and my
Lias le In full®toe and effect.and
7�5 PANELS
[.i...Cissa , LIe.X 0l
Date Contract. I<y
ARCHITECPSDECLARATION101-IWOAMPS
QO l understand my plane shall be used as public a. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
6^� OWNER•BNLDER DECLARATION $[+F-TIAL CIRCUIT/MIST 7s
7 pp. I hcmby a(@m that l am m exempt frothe Contractors Limme Law for the
OZ••� following reason.(Sedion 7011.5,Business and Prefeenione Code:Any city or TEMP.METER ORIOLE INST.
El county which requires a permit to cerutruct,alter,Improve,demolish,or repair
any structure prior to its baua^ce,also requlrce the applicant fmauch permit o O ppyyER DEVICES IIIc a.]gond statement that he is Ilcensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi.
O S SWIMMING 700E ELECTRIC
then3sis fo the alleged
d exemption.Any).mhoshe fSec ion therefrom and VALUATION
the basis for the alleged jeds thea p Anyviolationcivi of Section 7031.5 by any e 13 C7 0 O
G� applicanlfor a permit eubjeciatheappllcanttea civil pewlty o(na more/lun OUTLETSSWITCFIF&FIXTURES a� V
Eve hundred dollars . NEW RESIDENTIAL ELECTR SQpr. STORIES TYPECONSTRUCTION
I,as owner.(theheproperty,or my employee with wages a there sole
compensation,7iory Bu.Imsl do hewark,andthes Ccdcu Th not ndeddoe oimmoffered Law
Q .1.(Sec. pply Boniness andprofessions
property Co builds Compactors Umme law
�$ doe not a ssucin loan owner ofpropertywho buildsorlmprwelhereoryand OCC.GROUP RES.UNITS
who d.eeau a am n himself orough his own employees,however,
provided that such s
improvements sold within
earofredfortale.IShowevegthe ebuild rwill have TOTAL:
Improvement lewld within oneysaro(complellory the owner-build erwlll love
thttri rden of pmving that he did not build or Improve for pu rpose of sale,). QTy. PLUMBING P MIT FEE FLODD ZONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntractom to construct the project(Sec.7644,Business and Professions Code:
The Cont rector's License Law does oat apply to an owner of property who ALM-DRAIN&VENT•WA
bulks or Improve thurmn,and who contracts for m such pk0jewith a
�gp(pchorW licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for that reason
OUTS(DI,ITER
DRAINS FLOOR,ROOF,AREA,COD SANITARY Y N
Owner Date RECEIPT N
t,
WORKMAN COMPENSATION cam DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
JI hereby e(firm that I have a ttrtl(lete of consent to self-Insure,or RECEIPT X
3800,Lab
LLab
mC.) Sof Workers'Comperuation lruuranm oa mrtiflod copy thereat(Sec. GAEA.SYSIEN.I INC PARK FEE Y N
ab
Policy N RECEIPT N
CCAS EA.SYSTEM-OVER 4(RA)
or^ ^Y BUILDING DIVISION FEES
CcrtlSed copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEI' PLANCHECK FEE
CertBled copy at filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCECf SEWER-SANITARYEA Date Recef tp
Qhie section need no[be campiaed tithe pertmt at ionone hundred dollars
($100)orless.I WgTERF(FATQRW/VENT/ELECTR ENERGY FEE Y N
o
Ieartl/ylhat in the performance.(thewk for which this permit is Issued, —
I shall not employ an/person In any manner so as t t the
Wmkcre'C�1�,cnwIanV ( fornla.Date B WATERSYSTIM/TREATING PAID
O Z NbTICnt r7 5LI K 1�4 his Date Recei N!
Z O NOTICETO APPLICANT; Softer rtuHng that Cert ole of Exemption,you 'mow RESIDENTIAL PLMB. SOFT.
should become subject to the Workers'ComperwHan provisions of the Labor TOTAL:
tl) Code,you at forthwith comply with such provisions or this permit shall be
> deemed revoked. ,OQ
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercbyaf6rm that them at a construction lending agency for the perform ELECTRIC FEE
0 once of the workt.r which this permit at Issued(Sec.3097,Civ.Q TOTAL. ELECTRIC FEE
Lender's Name
IL I= lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtlfythatl have read this appllotbnand Matethatlheabovelnformatlon
a Iscorrea,Iagree to complywlth all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
> W relating to building meslructlon,and hereby suthrmcm representatives of this
1- Z city to enter upo hovnmentlorud property for Inspection purposes, ALTER OR ADDTO MECEL Date Recti til
- (We) to save, damnify an d keep harmless the City of Cupertino
against blBtles,Jed s,co&sand expenses which may In anywayaccme AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
agates as ence of the granting of this permit.
i
O AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of AppffiIirt/CbqtrxuI., Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H US MATERIALS DISCLOSURE
')
I nWillthe appllcantorfutum buildingomupant store or handle haysrdoua FIEATING UMT(TO 700,000 BTU) Date Recei til
on.r]al as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
!Flealth and Safely Code Sec1s1on25537(a)7 HEATING UNIT(OVER 100,000 BTM TOTAL: Z,
ye
Q Ye LrrLrs�pp�((���JJI
Will the appllcant A no building occupant use cqu 1pmet ordevlos VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousair cohhlaminante as defined by the Bay Area Air 01f,�
'apty Marsgement IXstdct7 BOILER-COMP OFIs DR 7 W,IXq BTM PA7�J"
Yen No
ve re the out mater].is requlremcnts undcrChap(er6.95 of BOILER-COMP(OVER 100,000 BTU) OCT ` � ����
tis.C.Ifornla Fleait'a,Safety Code,Seci]om255M,2S533and25S34. I V R
understand that a building does not currently have.tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
Papaiity a the occupant of the requirements which mat be met
Priem ssuanr f CeAifloteof Occupancy, City,
i. - Cu�RO
S (� ''tib//-TI-T�1—•� `
Ownerora d ant Date ISSUEDBY:
OTAL:
OFFICE COPY