21030 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProled identification PEfLv TNO.
Building A1d6«� �,��, 21030
wn s ams: one: A CA
O _ CITY OF CUPERTINO-BUILDING DIVISION 9��I L(�p�
l Cootrador.Name: �a APPLICATION I PERMIT
Am 4P24 _49—ttxN4�N / 2.1..?G BNLDING-ELECTRICAL PLUMBING-MECHAMCAL CATEGORY CONTROL
s �.rsglneer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.._._Sa—�/� / / 7 PGMITISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l em licensed under provisions of Chepter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwilh Sec onMOO)ofDivisim3ofthe Bu.inessand Pmf.1...Code,and my
license Is In fug f and effect. PANELS '
Lice..Class=Lie.# yZ-31" G
Date�1z_ Contract m/��CMUP TO 200AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
9 2CO I understand my phm.hah be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ft () Licensed Professional SIGNS ELECTRICAL
<<�6 Fkr1u OWNER-BUILDER DECLARATION SPECIALCIl2CL TIM
Zt• �a ' Iherebyaf@mlhat l.memmplfrom the Contractors License Lawforthe
pp following reason.(Section 7071.5,Business and Professions Code:Any city or
O Z H TIMP.METER ORPOLE INST.
c0untywhlch rcqulreaa perMltocowttvc[,alter,impmve,demoWh,orrepalr '
anystmdum pdorto Its issuance,also requlrestheappllcanl for such permit to POWER DEVICE$
Ole a signed statement that he Is Oconaed pursuant to the provisions of the
3 w0 Contractors License Lew(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
sion3oftheeuslnmsand Prcd.n uCnde)orthathelsexem therefmmand VALUATION
q 6 the boob for the alleged exemption. Any violation of Section 7MI5 by any OUTLETS5WITCHESfl%NRES �1 acv
WGa
applicant for a permit subjects the applicant to a civil penalty of not more L49
than (n
five hundred dollars(ISDO). NEW RESIDENTIAL FT FCTR SQ.FT.
�n [71,act owner of the property,or my employees with wages as their sole STORES TYPE CONS'IRI1C170N
C compensadon,willdothe work and the,tmcture is not intended or offered for _
'f q sale(Sec.7644,Business and Profession Code:The Contrad.e.License Law
does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUI' RFS.UMTS
whodom such work himself or through his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement issold within one yearof eampletion,the owner-W ilderwlil have
tlot burden of proving that he did nor build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE F=D"/DNE APN
u[as owner of the property,am exclusively contracting with licensed pggMpp L55IlANCE
rontractors to comtmct the project(Sec.7044,B.M..and Pm(easku s Code:
The Contrscter's License Lew does not apply to an owner of property who ALTER-DRAIN k VEVT-WATER(FA)
builds or improves them ,and who contras for such p[ojeaes with e
O�}R([actor(.)licensed pursuant to the Commetr'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See. B k P C for this mason
QUTqIUEjE
DRAINS FLOOR AOOF,AREA,GOND. SANITARY Y N
• Owner Date RECEIPT p
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI{OOL VAX Y N
hereby affirm that 1 have o Irs.m.e of consent to self-insure,ora RECEIPT N
cam lcate o(Warkers'Compensation Wurann oraadlfled copy thereof(Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARKFFE Y N
3800.lab C.) RECEIPT N
GAS F.A.SYSTEM-OVER 4(FA)
BUILDING DIVISION Fr.ES
Cedlrled pyb ercby(urnlMed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
nsedlffed copy Is filed with the city Inspection division.
7 CERTIFICATFOFIXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM RA.2701717. Date Recai tp
(This section need era tr completed If the pertNt ls(or am hundred dollars
(S100)oify that
WATER HEATER W/VENT/IB.EC'TR ENERGY FEE Y N
I cent employ
an person
in an?mannerhework so
lMsp subjecrmit I.t
iwed, —
1.hag era employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation haws o(Calilomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQ}T. Date Recei tic
Z O NOTICETOLICANT:1[.ft r,n kingthIs Certificate of Exemption,you
I" APPshould be..subject to the Workers'Compematlan provisions ofthe Labor TOTAL: _
N
Code,you=at forthwith comply with such provisiom orthls permit shall he
W deerrcd revoked. BUILDING FEE
LUG CONSTRUCTION LENDING AGENCY SEISMIC FEE s
I hereby affirm that them is a comtmctlon lending agency forthe perform ELECTRIC FEE
:) Z once.(the workfurwhlch this permit is issued(Sec.3097,Civ.Q TOTAL
u2 Lader.Name PLUMBING FEE
LL H Lender.Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedilythal l have readthlsapplicalio...d state that theabma
ove Information
1 lscorrcct.Iagree to comply with all city and county anRnances and state law, PERMIT ISSUANCE FEES PAID:
>. IO relating to building construction,and hereby auth.rin representatives of this
F city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu pertino
agalmtllabll )).,pdgt e,.A.andexpe.w.whtchmytnanywayamue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
ago Wte fty In a aeon of she granting of thio permit.
9�� �.
AIR HANDUNGUNIT(OVER 10,000CFM7 CONSTRUCTION TAX
Sig a A Icant/Cmntntlor Date — EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant.,future building occupant.t.m.rhandle haeardoua HEATING UNIT(TO 100,0D0 BTU) Date Recei t#
material as defined by the Cu Pert]no Municipal Code,Chapter 9.17,and the
Ilealt h and Safety Cede ctloo 25532(.)? HEATING UNIT(OVER 100p00 BTU) TOTAL: [�
❑Yea N.
Will the applicant or future building occupant use equipment or devices VFNITLAIION FAN(SINGLE RESID) ISc�}kyrfa7NllfbllA'FE
which coot hamrdous air contamleants as defined by the Bay Area Air JW
ATE
ManagementD t 7 BOILER-COMP p1IPORt6D,000 RTU)
4Yeso /y Ij]
have read the hau a us matcriatsrequiremenhunderChapterG95of BOILER-COMP(OVER 100,000 BN) SEP A 1990
the California I lealth k Safety Code,Sections 25505,75533 and 75534.1
u nderstand that if the building does not currently have atenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. rp (
responsibility to notify the occupant of the requirements which must be met MNQd 6UQ
prior lot ofa ficate of0coupancy. n aut [t o
Ow1&1fKUThdAfidagent Date TOTAL: ISSUED BY:C\`t'0-✓V�w'_""� •L
OFFICE COPY