21436 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
building Protect Identification PFRMITNO.
Building Address: 21436
blues ane:
At
9.,,�,S—' 1„ CITY OF CUPERTINO•BUILDING DIVISION p p
=Name re Name: LIc.N. APPLICATION /PERMIT
CIS– BUILDINGELPCTRICAL-PLUMBINGMECFIANICAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add PLUMB lv�lf
,6 v 7 PERMITISSUANCE El El 11LICENSED CONTRACTOR'S D LARATION
IhembyafflrmthatlamucrosedumerprwWonsofchapter9(commmc APPLIANCE4RESIDEMTAL JOBD ON
Ingwith Sect1on7000)o(Dlvlelon3 of/hc Buelnessand ProfesalonsCodc,and my
license la In full force,m effect. PANELS -
LlcenmCp Aa�i9 .A
—IM TQ 200 ANTS
COntnctorLic. eL .l
ARCHITECTS DECLARATION 101-1000 AMT'S
rs c4z lundemtandmyphmehaRbeuaedaspubgemmrds. OVERI000AMPS SQ. • .FLOOR AREA00
0 0 Licensed Professional SIGNS ELECTRICAL -
6 Fi7 OWNER-BUILDER DECLARATION SPFf_]ALCI(CUIT/M15C
Ihereby affirmt)ut lam exemptm
frothe Contractors License Lawforthe
oo O followingreason.(Section7R31S,Buslncaeand Professions Cods:Anycityor y
�
county which requires apermit taconutmct,alter,Improve, m
e,deolth,orrcpalr TEMP.METTRORPOLEINST.
anystmu mprdortoimt amalsorequimtheappBantforeuchper Ito POWER DEVICES
cG a file a signed statement that he Is Ikensrd pursuant to the provisions of the
Owl Contracmrb License Lav,(Chapter9(comntenmgwith Section 7000)ofDod-
'30 Non3olthe Business and PrefenionsCode)orthat hely exemptthere(romand SWIMMING R70L ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWH'CHESFD(TURES
applicant fora permit subjects the applicant to a civil penalty of na more than
(iv tuns owner of thepr. NEW RESIDENTIAL ELECTR SQ.FT. 5fOR1PS TYPE CONSTRUCTION
�n C sue owner of the property,or my employees with wages as their sale
compensation,wllldothe work and thestructure Is not intended or offered for
O sale(Sec.7044,Business and Pmf.I.ns Code:The Contuctols Lt..law
$� does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RES.UNITS
who doessuch work himself orthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.U howevcpthebullding or TOTAL:
Improvement t sold within aneyearofcompletion,the owner-builderwill have
hOrden offneving that he did not Wild or improve for purpose o(aide.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE O
mntracton to construct the project(Sm 7004 Business and Professions Code: 1Q
The Contucterb License Law does not apply to an owner of property who ALTER-DRAIN kVENTWATER IFA)
Wilds or Improves,thereon,and who centum m - -for such plu)ewith a FEE SUMMARY
c75actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I am nempt under Seo B k P C for this reason
•
Owner
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N- Date RECEIPTI
WORKMAN COMPENSATION DECLARATION N FIsTURES.PER TRAP SCHOOLTAX Y_ N_
hereby affirm that I have a certuane of consent to elf-houre,or RECEIPT#
I,Lab C.Workero Compeosatlon lruuunm Oraartl(led copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3g00,Iab CJ
Paltry M h O-O .3 0 0 3 RECEIPT X
Co anv GAS EA.SYSTEM-OVER�(FA)
([�[,ej, L•� BUILDING DIVISION FRES
13Certlfled copy t hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�§ertlEed copy b tiled with the city inspection division.
T CERTIFICATE OF EXEMPTION FROM WORKERS' CRFA.SETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.,00Fr. Date Recel t#
(TM1tuation need not W completed If the permit tlor ane hundred dollars
N100)orlass.) WATER HEATER W/VFM/ELECT- ENERGYFEE Y N
I certify that in the performance of thework forwhlch this permit
is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FI.. Date Recei t#
Z O NOTICETOMPLICt to
after making tet Certificate of ExemInto thelabo
F shouldbecameat
the ply with
Compeosa/bnprovtis permit s lab be TOTAL:
LU W deemed
o et forthwith comply with each provisions ortht permit shall be BUILDING W > deemed revoked.
ll G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm tlm then Is a construction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Clv.C.) TOTAL: /�
02 Lenders Name PLUMBING FEE 74
U. Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify that have read thtappbotlon and smothat theabove Information
incorrect.]-gree to comply with all cityand countyOrdlnanresa.d Nate laws PERMIT ISSUANCE FEES PAID:
). a relating to building construction,a rad hereby authorlu representatives of this
Zcity to enter upon the above-mentioned property for Inspection pu rposes. ALTERORADDTOMECH. Date ReCel t#
— (We)agicc m asve,indemnify a d kmp harmless the City of Cu peNlno
ago lost liabilities,judgment,costs and expenses which may in any way amuAIR HANDLING UNIT(TO 10,000CFM)s SUBTOTAL:
aga last said City In mauslu ence of the granting of this permit. Q
� ��' /�& —// AIR HANDLING UNIT(DYER 10,000 CFM) CONSTRUCTION TAX
Signa�Appiicent/C tractor Date ExtuIus'r HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBoest orfuture building occupant store or Media h.,dom HEATING UNIT(TO 100,000 BTT) Date Reeei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.1 1,and the
Iina Ith arad Safety Code Ion 75532(-)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: / aOD
❑ Yn o �.�.w.
Will lheapplkanl u re building Occupant use equipment or devices VENTILATION FAN((SINGLE RESID) �14a{I9 �CE DATE
which emit hamedous air mntmimnts as defincd by the Bay Area Air BOILER-COMP tI'OR 100,0(IO BTU) LLJr's�� .1a{
• Quality Management Dt1UN.0 ( �M '1 519�N
4 Yes yG}Na 14 D
haveread Health&Sa fetosteri Se requirements 5533underaChapte4. 1 of BOILER-COMP(OVQt]W,000 BTI)
the
ersta dt Health h Safety Code,Sectloos25505,ve a t nan,that. I
undentnlityl.( tifythbuilding does not currently havea.hiahLlhatBtmy NEW RESIDENTIAL MECFI. SQ.Fr.
respomibility to not]!ytheouupantoflherequlremente which must be met I I
P
riori sauce aCertl(late of Occupancy.
Owner or authodred agirest Date ISSUED BY:
TOTAL: —
OFFICE COPY