21089 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
BnilAlnq Add NUA .Q 21089
rl wners sees: one: p .
LIM
b11 CITY OFCUPERTINO6BUILDING DIVISION lO pJO
Contra or', ams: LIc.Na APPLICATION /PERMIT I•
BUILDING EM ECTRICALPLUMBING-MECFL LAICAL CATEGORY CONTROL a
Arc heel/Englneee Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmsa: PERhI7IS5UANCTi ❑ ❑ ❑ T
LIC ENS EDCONTR under DECLARATION ♦ �1
[hereby ion70 that)am licensed underprovisions Business and
Pro Chapter
ssion,9(commrn AI!PL[ANCESRESIDENffAL JOB DESCRIPTION
time.with I.In full
7000)of Dlvifect. the Buelneaeand ProleWone Code,and my $
LmmseCns j 2"0 .icii PANELS
Data Claes `-7..b Lk.M PT j
Data Contractor '
ARCHITECT' CLARAT 201 OVRR00 AMPS
�O I understand my plea shall be used u pubec records. /j ��-;.OVER 1000 AMPS SQ.FT.FLOOR AREA $/�.FT.
LImn.N Professional ,♦ SIC ELECTRICAL
OWNE BUILDER DECLARATION
SPFLIAI:CIRCUIT/MLSC
I it
s, f Thereby a(Brm[bathes accept the Contr3ctore License Law for the
2p following reason.(Section 70315,Bueineu en'd Pco(eubn.Code:Any city or �'
OZe.� P.METER OR POLE IN S .
K twntywhich requlreea periNltomNlruty titer,bnprove,demolbF,orrepak
mystruturc ptorm Wlisoance;aliorequlmstheapp0mt(m each pe of to POWER DEVICES
fib a signed wtement That he b Rcensed pursuant to the provfaluu of the
0w� Contratols Wceue Lew(Chapler9(conurcnWgwlth5etlion 7000)of Dlvl- SWIMMING 1, CTRIC
SOS alon3ofthe Buslneeeand Piofe�ou C"de)orthat hale vxempttheretromand VALUATION
C_ the bash(or the alleged e>remptlon. Any vlolatlon of Svebn 7871.5 by any
Ck?c appBmnl fore permit eubfeity tlfeappllcmltoa Avll penalty o(notrrory than Com'& SWIHES-FDTURFS
live hundred dollus(f50O). P
� �I,as owner of the propel,or�empbyem with ova esulhelr Bole NEWER LEI'p-CTRSQ'RC' S7pIBEG TYPE CONSTRUCTION
Z'< compeuatlon,willdothe work andthe.tmturebnot inters or o!(a aFd[or
❑ sale(5eq 7864,Bualneas and Profesilvu Code.The Contract le L'Ice/ue` w
e$ does not apply to an owner d property who WIIde or Imp t�I�eereoM d
whodoeseuchwork himselfurth aighhisawn employen,p Id(d that ch J OCG CROUP RES.UNITS
improvements aienotimended orofl,red forsil l4 howev th Al in r TOTAL:
Improvvmentlseoldwithlnoneyearofcompleio llw own, builderwillhave
t rdenof proving that he did not build or'Improve lm rpossofsaUJ. PLUMBING PERMIT FE LO
FODZONE APN
LJ L as owner of the property,am exclus;,Iy contra ng with llemsed PERMIT ISSUANCE
to consWt the project(Sec.7014,Busmass. massinu Code:
The Contratoes License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
Wilde or Improve.thereon,and who contracts far such pipjects with a FEE SUMMARY
�qRt$+tote)Ecenned pursuant to the Contntols License Law. BACK FLOW PROTECT.DEVICE LJ I am ezempt under Sec. B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
• RECEIPT
WORKMAN COMPENSATION DECORATION
ereby affirm that I have a mrtifimte of consent to aeB-[num,ora TURFS PER TRAP SCHOOL TAX Y_ N
N
RECEDT a
Nmte"1 Workers Compevatim ivuranm ma certlfkd copythercof 6ec. GAS EA.SYSTEM-1 INCA 0UTL PARK FEE Y N
?��INbCJ pa-LueP-2_WArj� RECERrrX
CAS EA,SYSTEM-OVER 4
Com env Ltt,,�/�QR uY 1 L._ BUILDING DIVISION FE ES
Certlfledcopy IsMerebyfumi. ed. CREASE/INDUSTRL WA INTERCEPTOR
ePLANCHECK FEE
rtlficd copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTAR STORM EA.2001 Date RCCe1pt4(
(This action need not be completed It the permit bfor one hundred dollars
($103)or leu.) WATER HEA w/VFNT/ELF-CTR ENERGY FEE' Y N
I certify that In the performance of th,work fo u to bpembi is bored, —
I shall not,mpari any person i any manner at u to become subject to the WATER SY /TREATING
Worker,'Campensatlon Gsys of GB(amla.Data PAID
-
z Z Applicant - NEW DENTIAL PLMB. SQ.FT. Date Recei tp
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become oibjed to the Workers'Compeasation provblaM of the Labor TOTAL:
4A Code,you mu at forthwith comply with such provblou or this permit shall be I
LU j deemed revoked.
LDING FEE
CL e CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyafflrm that them It a construction lending agency for the perform ELECTRIC FEE
Z anteof the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL:
V O ).ender'.N. PLUMBING FEE
F Lender'¢Address QTY. MECHANICAL PERMIT FEE
OW ludifythatlMvereadlhhapplmtbnand atethattheabovelnfornution MECHANICAL FEE
1 Iscormt.I agree to comply with all cityand county ordinances and gate laws FERMITLSSTIANCE 1,4,00 FEES PAID:
T W relating to building construction,and hardly authotm expreuntativm ofthb -
N Z city to enter upon the above-mentioned property for inspection purpose.. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei tp
V against llab(Btlro,' nts,mrtsand expenses which maylnmywa attroe AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agabut.ald City assn o Ire graining otthl. it.d�79a
L�.,//P AIR LI UNIT(OVER igOW CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE {L,
Will the applicant or future building occupant store or handle hazardous Y HEATING UNIT(TO 100,110O BTU) Date Recei CN
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Setion2553]A)7 HEATING UNIT(OVER 100,000 BTU) OU TOTAL:
n Ym , r!No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IN40F ]CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air IN40F
. Quality Management District? BOILER-COMP OHPOR 100,000 TITLE)
4 Yoe 9 No qq
Yost
read the haze o..m ortab requirements underChapter6.95 of ROLLER-COMP(OVER 100,000 BTU) 1 q
s the Glifomh HealthA9fety Cod,Seticu25505,75533and25534.1
understand that lithe building doe.not currently have a tenant,that Itbmy NEW RESI DEN71AL MF.CH. SQ.FT.
responsibility to notify the occupant of the requirement,which at be crest
prior to exuanm of a Certificate of Occupancy.
Owneror.whoriecd agent Data
TOTAL: OD ISSUED BY:
OFFICE COPY