21339 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMIT NO.
Building Address:
4115-6 c4—'� Le4lf 21339
neva one: q A
AQ m e e'1 'I(I CITY OF CUPERTINO-BUILDING DIVISION 10
/ d
-� Contractor's au� Linc n APPLICATION I PERMIT
r Name: BUFLDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROLp
Archite t/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTe under provisions
Ihereby diofir )ofamsim3 ftheBuJrosa dPmfehapter9(commeno- APPQANCESRESIDEN7TAL J08 DFSCRII'DON
'ngwith Sectton70W)of Dlvielon3o(the Businnsand ProfesslonsCode,and my
licenssle in"' rce and effect PANES
License Class Llc.p S���Q - �0o�
Date Contractor i d
ARCHITECTS DECLARATION 201-1 OOB AMPS
2 I understand my plans shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
u�OSELEC7RICAL e
Licensed Professional SIGN__ „
<<ce OWNER-BUILDER DECLARATION a 15
`In SPECIAL CIRCUIT/MISClhere1
p., 7 owing yaf8s.Sectlamexemptfromthe Contractors Code:Law fort he
7 0.: following reason.(Section 7fU1.5,Business and Profession Code:Any city or �4
O 7 F TEMP.-METER OR POLE[NST.
countywMch requires a pemdt to rovtmuirosthea provq dforsuc ,or mit to
gF� a6a anya signed statemprisetoent
t that
heeq licensed
pursuant to the forauc
permit y�g DEVICES,
'S 0 U file a signed statement that he t licensM pursuant to the proWslofe the
Contractor's License (Citi erg(comnRncln Ith Sedlon7of Dlvit r r
�$wr pt gw SWGMNG (OL1ELECTRIC
VALUATION
0e slon3ofthe Business and Profession Coded or
hese exempt the' m.cl
the basis for the alleged exemption. Any violation of Section 7QICy any p I'
GS OUTLETS-SWITCHESHXTURES� S -0 -
applicant
dred furs the applicant to dull penalty of ratre han
five hundred dollars(5500). ' . NEW RESIDENTIALELECTR'�
�Cj ❑I,as owner of the property,or my employees with wages ait dole - �'�' STORIES TYPE CONSTRUCTION
5 ¢ compensation,will do the work and the structure R not Intended orfor \ ^ L
O sa ie(Sec.7044,thudesseand Profession Code:The Contrador's LTrenelasy
Ny R does notapplytoanownerofpropertywhobuildsorimprovesthe..,Iana 1 ` OCC.GROUP RES.UNITS
who doessuchwork himselforthre fth hisownemployeea,provided that&rch
Improvements are not Intended orofferedforsale.If,however,thebulldingor ` , TOTAL:
improvementis idwithinoneyearofcompldion,theowner-buiiderwillhave
tryAIl+rden ofpmving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PFRMITISSUANCE
contra&..to control the project(Sec.7044,Business and Profession Code:
The Coritador's Limnae Law does ncc apply to an..or of property who ALTER-DRAIN&VFM-WATER(FA)
builds or Improves thereon,and who contracts for such ptojects with a
cdor(s)llrensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
6FEE SUMMARY
am exempt under Sec.
B k P C for this masonOUTS I UP FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION pD(TURES TRAPPER TRSCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT p
certificate ofWorkeri Compensation[nsuranmora rertRled copy thereof(See. GAS-EA.SYSTEM-1 INCAO=ETS PARK FEE Y_ N_
REZEU3800,Lab C.) n t
CIIT q P 4T GS�UI GAS EA.SYSTEM-OVER 4(EA) BUILD NGG IVISION FE ES
�Cerytified copy k heed with the
city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
1-7jJertified copy Ls filed with the dty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 20017' Date ReceI t#
(Thissection need not be completed if the permit f;forone hundred dollars
($IW)or less') WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in the performance of the work for which this permit la issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQF. Date Recel t#
ZO NOTICE TO APPLICANT:If,after nuking this Certificate of Excerption,you
should become subject to the Worker'Compensation provisions of the Labor TOTAL:
h N Code,you must forthwith comply with such provisbv or this permit shall be BUILDING FEE
9 deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Thereby affirm that there is a construction lendingagency,forthe perform, ELECTRIC FEE
Z ance uftheworkforwhichthb permit is Issued(Sec.3097,Civ.C.) TOTAL:
00 l.endersName TY. MECHANICAL PERMIT FEE PLUMBING FEE
LL F tenders Address Q MECHANICAL FEE
U IuAifythat]have read thisapplicationand statethattheabove Information
0 W iscorrxt.I agreeto comply with all city and coomyordirsomsand state lawn I PERMIT ISSUANCE FEES PAID:
CL relating to building construction,and hereby authorize representatives ofthb
F Z city to enter upon the abovnmentloned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmlesa the City of Cuped Ino Date ReCei t#
V
against liabilities,judgments,costsand expenses which may In any way acerue AIR HANDLING UNIT(TO IQ000 CFM) SUBTOTAL:
againstId city is consequenceti
of the grant of this permit. �RHANDWNGUhTTOVERIO,OWCM)
. CONSTRUCTION TAX
_
Signature of Applicant/Contractor Date EXHAUST HOOD IN/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardoua HEATING UNIT(TO 100,00 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 93Z and the
Health and Safety Code Sed 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: .S
❑ Yes
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSIJ.AV DATE
which emit hamrdoos air contaminants as defined by the Bay Area Air 1''
Quality Management District BOILER-COMP QHP OR 100,000 BTU)
4Ycs o
have read the h axardous materials requirements u nder Chapter 6.95 of BOILER-COMP(OVER 100,0008711) OCT 9 6 199Q
the California I lealth h SafetyCode,Sections 25505,5533 and 25534. I
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which most be metaa�pwn^
prior ssuance ofd Ce fic,iteofOmpancy. ,,// VL f!�aFi ac
o CICO ��
Owner or authorized agent 'DaLt4�7
e ) z
TOTAL:
OFFICE COPY