21461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
Building Procct Identification PERMIT NO.
Building AddroOdr:
u7iloE��c7 21461
Q �NGI� 2.
wners ems: one;
.p CITY OF CUPERTINO-BUILDING DIVISION q
cantraamr'°Name: urs Na: APPLICATION I PERMIT
Architect/Engineer. LM.Na: BUILDING-ELBCTRICALPLUMB/NG-MECt{AMCAL CATEGORY CONTROL N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add... PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
T hereby affirm that l am licensed under provisions of Chapter 9(corromme. APPLIANCESRF9DENHAL JOB DFSCRI'ITON
Ingwlth Section 7000)of Division 3 ofthe Business and PrefesslonsCade,and my
license 1.is(uB force and sled. PANELS �x�
LicenseChr LIc.N I//-1'1
Date Contractor UP TO 2DOAHM
ARCHITECTSgepqo-
DECLARATION 201-1000AMPS
q�v O ZO I understand my plats shag be used as public rcmrdL OVER I OOO AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
j�b Licensed Professional SIGNSELECTRICAL
6OWNER-BUILDER DECLARATION
`!n a SPECIAL CIRCNT/MLSC
Zr„ Iherebya(Or 0;ectia 70312, tfromthed Pretensions
License Lw fort he
FZFoo countywreamn.(Sectionrmitle Busher and Proferve, Code: city or
't9i . �cwnty which requlmapemdtromroWR,alter,Improve,demolish,arrcpalr 7IIdP.Mb71A OR POLE INST.
g� anystm=mpH toils Wuame,alsomquinstheappliMAt(orsu=hper ito POWER DEVICES
E5 O file a signed statement that he b licensed pursuant to the provblons of the
3c" Contractor's Licetoe law(Chapter 9(commenMg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
1�Oe slon3althe Bueinnsand Pro(erloru Cade)artAsthebexemplthcrc(romand VALUA116N^
<l the basis for the alleged exemption. Any violation of Section 70315 by any OIITLETSSWITCFIESFIXTIIRES 6 O l O V
applicant fora permit subjeatatheapplicam to a civil penalty of not nnre than Q
Ove 1,as owner
of the pr. NEW RESIDENTIAL ELECTR SQ.Fr, STORIES TYPE CONSTRUCTION
a,
10 1,a°owner o!the property,or my employees m with ween r their sok
rompers.70K Band na,e work and the ewamreh rot intended or offered for
O roe(Sec 7046,Business and Pro(mror Code.The C Impary s License law
does nal apply to an owner of property who build°to improve thercory and
who donsuch workhlmselorthrough Msown employees,provided that such OCC.GROUP RES UMTS
Improvements erc not Intended or offered for sale.If,however,the building or TOTAL:
Improvermnt b°old within one)earofmmpletlo4 the mvner-budderw111 have
IELIIurden of proving that he did not bund or Improve for purpose of sale.). QN. PLUMBING PERMIT FEE FDA ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed
contractors to construct the Seel PERMETLSSUANCE
prodoe( fppl t Business and of prop rCode: a 011
The Contractor's impo'e Ucerue Lw don not apply ct an owner of property who ALTER-DRAIN A VENT-WATER(EA)
bulimia t r improve tpursuant and who contract.users for se L plo)ecb with a
,,!!L�¢++ctmexe plunder Sm
the Conmacto/s License Law. BACK FLAW PROTECT.DEVICE FOUSUMMARYOUTSIDE FEES cLI I am exempt under Sec B& P C for this reason
Owner DRAINSflAOR ROOF,AREA,COND, SANITARY Y N
• Date RECEmT N
WORKMAN COMPENSATION DECLARATION IV('NRFS PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a certificate of consent ro rlf-Insure,m a �• B D RECEIPT N
cercificateo(Worken'Compevatlonlnunnce oraceHlficdmpytherm!(Sec. GAS F.A.SYSTEM-1 WC.d OUTLETS PARK FEE Y N
3800,Lab C.)
Policy N GAS EA.SYSTEM-OVER 6(EA) RECEIPT'X
Com any BUILDING DIVISION FEES
�CertlRad copy b heed with the
city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑ ed
Certified copy b filed with the ctty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhle section need not be completed I the permitSURA b(ororie hundreddollars SEWER-SANITARY-STORM EA.2IDFr. Date Reel t#
($1 mtthat
th WATER HEATER w/VENT/ELECTR ENERGY FEE Y N
unity at rothe performance of the work for which this permit is Weed,
I°hal not employ any person In any�anner m n to �p wbjeR to the WA.I.Qi SYS.fGM/TREATING PAID
-
0
CompensyMt ( rqa,Dme M
Z0 Z ApplNUIICnl� NEW RESIDENTIAL PIMB._ SAFE. Date Recel t#
O NOTICET�bj (,aR�m'C.mpbsid In.pro o(Exemptlenf,aR�m'C.mplssid In.lpro o(Fiemptlory you
ahmldbecame forth to the Workers'such provisinprovblomofthe Labor TOTAL:
W W Coda you olsat ed.forthwith comply with each provisions or thin permit shall be x D
� deemed revoked. BUILDING FEE
W 'c CONSTRUCTION LENDING AGENCY SEISMIC FEE t
I hereby affilhatthereba construction lending agency for the perform ELECTRIC FEE
M Z onceo(the work(or which thbpermit is Issued ISM 3097,Civ.C.) TOTAL: .
O 0 Lender's Name PLUMBING FEE
CL h- Lender's Address QTY. MECHANICAL PERMIT FEE
OMECHANICAL FEB
U Icertltythallluvercadihlsapplieitian.rami statethat theabave informs"':W bmrmet.Iagreeto=omplywithallcityandcountyordlnanreeanddatelaws PERMIT ISSUANCE 12. 60 FEES PAID:
>_ a relating to building constmetion,and hereby authorize rep.. ....vea of this
I— N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnity,an d keep harder the City of Cu Farina Date Receipt#
V against habiltles,judgments,cents and expenses which may In any way name AIR HANDLING(IMT ITO 1n,00m CFM) SUBTOTAL: �0
against said City In consequence of the grant Ing of this permit.
AIR HA NDLING UNIT(OVER 101000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(4V/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe appncant or future bulldingoccupant store or handle harardous HEATING UMT(TO 100,000 BTU) Date RCCCIDt#
material as defined by the Cupertino Municipal Code,Chapter 9.lZ and the -
HealthandSafety Code Section 25532(a)? HEATING UNIT(OVER100,000BTU) TOTAL' • O D
❑Yen M No
Willthe applicant orfuture building occupant use equipment ardevlcea VENTILATION FAN(SINGLE REBID) Z (`D ISSLr6,)�ATE
which emit hamrdous air contaminants as defined by the Bay Area Air v fC
Quality Management District? MOILER-COMP OHP OR 100,000 BTU)
4 Yee ua " a�ao
fiave read the hoz ua materials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) N� `9 I
the California Iimlth k Safely Code,Sect lone 75505,25533 and 25536.I
understand that lithe building does not currently have atenanL that It is my NEW RESIDENTIAL MECH. SQ.I7.
responst Illy to notify the occupant of the requirements which must be mot /sTgr .e4/1..�.rd:�
prior to lrua ( Cert ateafOTcyepa / -(/) W5Y W WI165N
rorau agNd — etc �O'� 7%IJLU BY:
TOTAL:
OFFICE COPY