21390APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:21390
PERMIT NO.
1115 S
Y�, oy_s Looio,.� 257-1gM
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION/PERMIT
BL7LDINGELECTRICALML BINGME LAICAL
L DAIL
1� A
I Slgd
cuntraau%sNares: jCLie.No:
•""'���Y .JJ
CATEGORY
CONTROL
rchimet/Engiarer: Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMHISSUANCE
X— ❑y� E]
LICENSED COpNTRACTOR'S✓ DECLARATION
ECLARATION
hirmtht lamkenunder provisions Chapter9(mmmenc
ingwthSxedo1000o(ae3.ftha Buslnessaed Preload omCde,andm
or
le In fes d effect O
LiDimkatenen_asc)c .
Contractor Q50?%r
T
ARCHITECTS DECLARATION `
I understand my plan shill W used as public records.
APPWANCESRESIDENTIAL
f1:1
]OB DESCRIPTION
�
PANELS
70b10W AM
OVER 1000 AMPS ,^
SQ. FT. FLOOR AREA
/SQ. FT.
SIGNS ELFLTRIC L [�
Licensed Professional
OWNER -BUILDER DECLARATION
I hercbyalOmntMtlam exempt(mmthe Comraeors Llrenx Law for the
followingreason.(Section PMIS, Business and Pmfeaalon Code:Anyeltyor
ountywhi&mquircsapermhtomntmd,altegimprove,demolhh,orrepair
anystnrcture priorto its Issuance, also requirestheapplicant for.uch permit toPOWER
SPEGIA GIItCNTjMISC
-
Y
7LMP.M OR TOLE INST.
DEVICES
- '
file a signed statement that he h licensed pursuant to the provhbn of the
Contractor's License Law (Cha pter9(commencing with Section 7000) of Owl.
.Ion 3ofthe Businemand Profmn mCade)orthatheheumpttherefmmand
the bash for the alleged exemption. Any violation of Section 70315 by any
app llcantfor a permit subjects the applicant to a civil penalty of not morethan
five hundred dollars (5500).
❑L as owner of the property, or my employees with wages as their sok
SWIMMING IX)OI:FlECfRIC
I - -
\ E N I \\ V
cTLETS-SWITcHESFLXiURES
VALUATION
I J Qhs Cz
_
NEW RrADENTIALELEC s .
�'FT
STORIESYPECONSRUCTION
mmpensation,w81 do tM work and thestmcmm h not Intendedor offered fes
sale (Sec. 70K Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
whodoessuch work himselforthroagh hisown employees, provided thatsach
®
s
OCC.CROUP
RES. UNITS
Improvements are not intended oroffersd forsals. If, however, thebulWing or
TOTAL:
improvement issold within oneyearo(completion, ted owner -W Bd erwill have
QTY. PLUMBING PERMIT FEE
thij,urden of proving math dm net baud or improve for purpose ofsale.).
" L as owner of the property, am exclusively contracting with Emned
contractors to contract the project (Sec. 7044, Business and Professlon Code:
FLOOD ZONE
APN
Pf72M1T ISSUANCE
The Contractor's Llmnse Law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such Pro)ecb with a
cottBBffaetoKs) umnsed pnrsnant ro tha cantraeor. uren.e law.
LJ I am exempt under Sec. B h P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
DRAINSFLOOKROOF,ARFA,COND.
SANITARY RFLF N
Owner Date
WORKMAN COMPENSATION DECLARATION
�1 hereby affirm that I have a mrtiBote of consent to self -Insure, ora
redificateofworkers Comper tloninunnmoramrtlfWwpythereof5ec.
3800, Lab C.)
FIXTURES- PER .).RAI'
SCHOOL TAX Y N
RECEE T N
GAS EA. SYSI'EM-4 INCAOUILETS
PARK FEE Y N —
RECEPT X
Policy X
Cam any
GAS FA. SYSTEM-OVER4(FA)
BUILDING DIVISION FEES
�Cchtfied copy h hereby furnished.
OCcrtlfied copy h feed with IM city Inspection division.
GREASE/INDUST1tL WASTE INTERCEPTOR
PLANCI-IGCK FE6
GREASE TRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA.]OOFT.
COMPENSATION INSURANCE
(TBlssadi ced nut M completed if the permit h for one hundred dollars
Date Rem) t#
WATER I-[FA.I.FR W/VFN.I./ELEC.I.R
ENERGY FEE Y_ N_
($100)orleux
1¢rtifylh t the perfomanre of the work farwNc thio permithhwed,
WATER SYSTEM/TRFAUN'G
I shoe note y any pe say manner m ELb;- m the
Workcri Co nation llfomda Date Oo
e o
PAID
ApPecont
NEW RESIDENTIAL PLMB. SQFf.
Date RCeel t#
NOTLCE TOM LICA T: H, ft makingthh Cenelote of Exemption,you
shwid become aid, to e o n'Compensatlon pmvhion o(the Labor
code, youawuforthwRhcom with such provhlenarthh permitshall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
TOTAL:
BUILDING FEE
qW
SEISMIC FEE
_ l
TOTAL:
ELECTRIC FEE
I hereby affirm that there is a contmtllon lend Ing agency for the perform
ance of the work for which this permit h issued (Sec. 3097, Civ. C.)
Lander'. Name
Lender.Adder.
i mnlfythatl Mve rea lthisappliotlonand satethat theabove Information
is correct. I agree to comply with all city and county ordinances and state laws
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building contraction, and hereby authorize representatives of this
city to enter u Pon the abovormationed property for inspection purposes.
(We) agree to save, indemnify an it keep harmless the City of Cupertino
against liabilities,judgments, mssand expenses which may In anyway accrue
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT(TO 10,ODO CFM)
SUBTOTAL:
—
-
aga Inst said City In con.ryuence of the granting of this permit
AIR I;ANDLINGUNIT (OVER 10,W0CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUcn
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 10),000 BTU)
-
Date ReCe) t#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Ilealth and Safety Code Section 75537(a)?
0 Yes u No
HEATING UNIT (OVER I00,OM BTU)
1
f {;TiVAL:
3 'SSI
VENTILATION FAN (SINGLE RESID)
SUANCE,DATE
NOVGU0 Isqu
City C4 Pum 'st►inr�
Will the applicant or lower Wilding occupant use equipment or devices
which emit liar does air contaminants as defined by the Bay Area Alt
Quality Management District?
4Ys �No
read the haze cam material requirements under Chapter 6.95 of
the lie hHealth ASafety Code, Section 15503, SSi7 and 75534.1
BOILER -COMP DIIP OR 100,000 BTU)
BOILER -COMP (OVFL2100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
und[rstarafhat if the building does not currently have a tenant, that it Is my
nibl yto notify the occupant of the requirements which must be met
p uance ofa cof Occupancy.
ISSUED BY: '10 a' �`��
norm orlu agen a
TOTAL:
OFFICE COPY