21887 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruset Identification PERMIT NO.
Building Address: n a� �'1
l�'cv R • v✓0 G I 8�JJ{
en aces: one: APPUCAIIO SUBMEIIALUA
CITY OF CUPERTINO-BUILDING DIVISION /'
Contractor's Name: Lle.No: APPLICATION 1 PERMIT '7
s
Aiteci/Engine BUILDING-ELECTRICAT PLtIMOINGMECHANICAL CATElORY CONTROL N
Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: OO5.5"�CPERMITISSUANCE ❑ 1'y
LICEN D CONTRACTOR'S DECLAR ON U Dr
I hereby affirm that l am licensed under provisions o(Chapter9(mmmenc AFPWANCESRESIDENTIAL ]OB DESCRIPTIONIngwlth Section 7000)of Dlvision3ofthe Buus�lneeaand PmfessionsCode,and my 1
LIczmz Cha7L
m fY S tX 6�9Z 9 PANELS
Date Contractor
ARCHITECT'S DECLARATION 201-1000AMPS
ra Z I undpiets2�I be used as public remmd4 iOVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
00 /ll
re `j Li nal SIGNS ELECTRICAL
<�6 OWNER-BUILDER DECLARATION Spp-C)ALCIliCNT/M1SC
Z I., Z,, Ihere9
byarm that l am exempt from the Contractor's License law for the
following reason.(Section 7915,Business and ProfroWns Code:Any city or
OF t: TEMP.MEIFR OR POLE IN
�
county which requires apermit toconstruct,alter,Improve,demolish,or repair
qqq Q anyatwcmn prior to itsbu.rw,abo requires th..pplicant for such permit to POWER DEVICES
ryG U file a aigned statement that he is licensed pursuant to the provisions of the
3 O Contactor.License Iaw(Chapter9(commencing with Section 7000)of DWI- SWIMMING POOL ELECTRIC
sion3o(the Businemand Profemions CW.)orthath.ieexemptthemfromand ALUAJION
Q the balls!or she alleged exemption. Any violation of Section 7915 by any OUTLETS SWITCHES FIXTURES
appBant far a pemdt subjects the applicant to a civil penalty of not morethan /
five hundreddollarsheprE$M. NEW RESIDENTIAL ELECTR 5Qd7. STORIES TYPE CONSTRUCTION
�n ❑Las owner of the property,or my employees with wages thele sok
compensation, notintended or iofferedfar
O sale(Sec.70K to an owner
df property
Code:The or Impmes heroncense Law
does doeot s
such
loan imserofprope hhiso nembuildorlmprovesthereoryand OCC.GROUP RFS.UNITS
who doeswchwork tIntededoroffe downemployees,providedthatwch
improvements am issold ithindneyearfemd(oruk.the over-builderwilingm TOTAL:
improvement.sold within oneyearafcomplMlonthaowner-bulWerwlll have
theeburden of proving that he did net build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Fj L ae owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7004 Business and Professions Code: PERMIT ISSUANCE
The Contactors Licanse law does not apply to an owner of property who ALTER-DRAIN Is VENT•WATER(EA)
Wilds or Improves thereon,and who contracts for such pkajecb with a
cj5actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. 0&P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
WORK MAN COMPENSATIONRECEIPT M DECLARATION F0(TURES PER TRAP �- SCHOOL TAX Y_ N_
�I harcby affirm that I have uw
e a rtlfkate o!consent to self-Inre,ora RECEIPT S
309380,Lab ab CJ SYSTEM-1o(Worken'Comperuatlanlnsuranceara rertl(led copy thereo((Sec. GAFA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
,
REC
Policy a CAS EA.SYSTEM-OVER 4(EA) DING DI N
Com any BUILDING DIVISION FEES
[�Certifled copy Is hereby furnished. CREASE/INDUSIAL WASTE INTERCEPTOR
FEE
Certified copy bi tiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date ReoDi tN
(T on need not M completed If the permit V(crane hundred dollen
(5190
morl..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that o the per(mm I.sof tha work so as to
co permit is to the
I haloris not employ an/ Um in any manner at as to berorne wbject to the WATER SYSTEM/TREATING
Workers'Compensation Um.f Data PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.PT. Date Recei l71
Z U NOTICE beOAPPLICAM:IL after W.rs'Co perutionlareExemption,you
shde,you ma wrthwitct the Workers'such provisions
provisionspermit s Lab be TOTAL:
a. > dermedi =at forthwith comply with each provblom orthk permit shall be
W deemed BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL O Ih Rhea Brmthatthere kacomwRlsu lending agency for the perform- ELECTRIC FEE
7 Z an Mdae.Nwork(or whkhah6 perMtls bored)Sec.3097,Civ.C.) (OTA
LL O Iarae/.Noma PLUMBING FEB
ly — Leneer:Aaare.a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Imeifythatl have read this applicationarl Werthauheaboveln(oonatim //��
O W kcormect.I agreeto comply withal)city and county ordinance and pate laws PERMIT ISSUANCE QV FEES PAID:
} IL relating tobulldlngmmtwction,and hereby authorize representatives ofthis
f" N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MRCH.
Z (We)agree to save,indemnify an d keep harmless the City of Cu pert lno Date ReceI lis
V against lkbillties,judgments,was and expenses which may In any way seems AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL'
against said City In consequence of the granting of this permit.
AIR HANDUNCUNIT(OVER lD,000CFM) CONSTRUCTION TAX
Signature of Applimnt/Contractor Data E7(HAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies rat or future building occupant store or handle hazardous HEATING UNIT(TO 19,000 BTU)
materia l as defined by the Cupertino Mu nicipal Cade,Chapter 9.12,and the Date ReceI tN
Health
d Safety Cade Section 2S532(a)? HEATING UNIT(OVER 100,(X)BTU) TOTAL:
M Yen
Willtheappiicant No
use equlpmentordevices VENTILATION FAN(SINGLE RESID) IS§{aI�Ii1�DATE
which emit hazardous air contaminants as defined by the Bay Area Air 1L�E
ality Management District? BOILER-COMP QHPOR 100,09 BTU)
11 Yes J[ No
juTread the M1aZr uematerials requlrementaunderChapter 6.95 of BOILER-COMP(OVER 19,09 BN) ,nR 419t
the California Health&Safety Code,Sections 25505,25533 and 25534. 1
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.PT
respomi idly to nctlfy the occupant of the requirements which at he met
prior to kvmnce of a Certificate o(Ouvpanry, C� ✓�����
Owner or authorized agent Data
10T s
OFFICE COPY