21713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Address:
Building Protect Identification L—U— Man �wk,T� rE�LwrN21713
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L• CITY OF CUPERTINO-BUILDING DIVISION .I _ _ a 1
S c rano .xa L r. APPLICATION / PERMIT cAlTcorsv CONTROLX
BUILDING-ELECTRICALnU BING-MECIIAMCAL
ect gin :. .No:
C QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrn>: 1rQth0TIS5UANCE �tc�
LICENSED CONTRACTOR'S DECLARATION (�
T hereby a(flrm tHtlam llcenaed under
IngwhSeaton 3oftheguspinroesyshainednsof C9(commeAPPLIANCES-RESIDENTIAL
Pore.,1or.Codeandmy ;OB DE-
SCRIPTION
license is to e,u force and died.
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Clan nt
Dattee Coontractor
ARCHITECTS DECLARATION 701.1 COO AMPS
qqqq ol 77. I understand my piansahallbe used an publlereconls. OVERIODOAMPS SQ.IT.FLOOR AR $/SQ.FT.
u Licensed Professional SIGNS ELECTRICAL
<Z. OWNER-BUILDER DECLARATION J/TV,•`J
(-east SPECIALCIRCUIT/MISC ✓✓✓vvv --_
L,iA 7 I herebyalRrm that I am exempt form the Contractor'.License Law for the
Z O lolbwing reason.(Seetlan 7071.5,Bushuses and Professions Code:Any city or aa//
07 HcountyrequiresFerrefttocenstmot,alter, TEMP.MEIPR OR POLE INST. L/;r
s.a any nwcned uturto ltahat he
lice sed poignant t the formions of its POWER DEVICES
5 Pile a signed statement that he h licensed pursuant to the provisions of the
i3 rcContracto/.Lice.Taw(Chapter 9(commencing with Section i 7000)of Divl-
O G SWIMMING IDOL ELECTRIC
1� cue basis fo thealleged exemption. Any orlation f exempt therefrom and VALUATION
the bash for the alleged exemption. Any violation d Section nei m by any OUTLETSSWITCHESFIXTURES /�� / ,
555 pO fiveapplicantdred.permit subjects the appllcanttoa civil penalty dnot mom than /`//
o i five hundred dolbra RSOD).
�I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIALELECTR SQ.FT. STORIES TYPECONSIRL'CTION
C compensation,will do the work and the structure in not Intended or offered for
n sale 51,70K Business and Rofeaalons Code The Contractor.License Law
X57 $ dm not apply to an owner of property who build.or Improves thereon,and
c-s^ who does suchwork himself or through his own employees,provided that such OCC.CROUP RIS.UNITS
Improvements are not intended proffered forsale.If,however,thebulldingor TOTAL:
Improvement h sold within one year ofcompletlon,the owner-bullderwill have
ttq rden of proving that he did not build or improve fur purpose ofuleJ. QTy. PLUMBING PERMIT FEE ROOD ZONE APN
—1 I,as owner of the property,am exclusively contracting with licensed pUfMIT ISSUANCE
contrectors to construct the project(Sec.7014,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTQt-DIUIN&VFM-WATER(FA)
Wilds or Improves thereon,and who contracts for such ptoje is with a
cgatIactor(s)hamsed pursuant to the Contractors License Law. BACK FLOWI'RO1lLT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B 4 P C for this reason
S
DRAINS FLOOR ROOF,AREA,CONT). SANITARY Y_ N_OUTSIDE FITS
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURFS-PERTRAP SCHOOL TAX Y_ N
❑1 aereby affirm that 1 have•ce gur.e of consent to self-Insure,hereo ora RECEIPT N
certificate ofWmkeri Compevatloninsuranre ora certilled copy thereof(See. GAS rA.SYSrEM-1 INCA OUTLETS PARK FEE Y N
3900 Lab CJ
I'o11ry N RECEIPT N
Com any u.a4f1 PC.r c��. CAS GA.SYSTEM-OVER 4(FA) BUILDING DIVISION PEES
anyrtfiled
copy h hereby tome city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
QCertUed copy's flied with the city Inspection divlalon.
CERTIFICATE OF O(EM"ION FROM WORK ERS' GREASE TAM PAID
COMPENSATION INSURANCE // 3G
(fhesectlonneed not hecompleded lfthepermlt hforom hundred dollars SEWER-SANITARY-STORM EA.ZX)FT. Date Rccei t# >i
(910 mhifya.)
1 oily WATER HEATER W/VENT/ELECIR ENERGY FEE Y N
that lo the perforrtun¢of the work forwhlch this permit b issued,
I shall not employ any person fn any manner ac,as to become subject to the WATERSYSTEM/TREATING
workers Compensation Laws of California.Dae PAID
0Z Applicant NEW RESIDENTIAL PCMB. SQFT. Date RCfPI t#
Z O NOTICE TO APPLICANT:If,after making this Cerflfiate of ExempOon,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
~ N Code,you must forthwith comply with such provisions air th is permit shall be
> deemed revoked. BUILDING FEE
0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hemby affrmthat them h a construction lending agency for the perform ELECTRIC FEE
Z an¢oftheworktorwhichthhpermithhsued(Sec.30Y/,CIv.CJ TOTAL:
V _O Lenders Name /� PLUM BING FEE
LL ~ Iender,Addreaa �T QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1¢nlfyihatlluvercadthhappli tionaed aatethatheabovdnforsatfon
hcorrect.I agreeto comply with all city and county ordinances and state laws PERMITISSUANCE FEESI I /_
�. L relating tobullelingemetructlon,and hereby authorize representatives ofthis - // 'Y&f%
H Z city to enter upon the above-mentioned propertyforhupectlonpurposes. ALTERORADDTOMFCH.
_ (We)agree to uve,Indemnify an d keep harmless the City of Cupertino ate Receipt#
against llabNttes,judgmens,cvNural expensowhich may In anywayamue AIR HANDLING UNIT(70 10,000 CFM) SUBTOTAL:
against said City1in mpsequence qI the granting of this permit.
✓/_Vi/J / / AIR HANDLING UNIT(OVER l0,000CIM) CONSTRUCTION TAX
Slgwtum of Appli t/Contractor Date EXHAUST HOOD(W/DUCT) CrON�z.PAID:
A]A RDOUS MATERIA ISCLOr hand
Will the appllant or(utvrt buildingo ant atom or handle havrdous HEATING UNIT 100,D30 BTU) Date Recei t#
m terhl as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Iivahh and Safety Cade Section 25537(a)? I']EATING UNIT(OVER 100,000 BTU) TOTAL:
O Yes - M No
Will the applicant orfrturobuildingoavpant use equipment or devices VENTILATION PAN 03INGLE RF_SID) ISSUANCE DATE
which emit havrdous air centamiiants as defined by the Bay Area Air
Quality Management District? BOILF.R{OMP QHPOR IMOM BTU)
YesF❑�No
e
Tuve readthe havrOssuterlah requirements under Chapter(05 of BOILERCOMP(OVER 100,000 BTU)
the California Health&Safety uCode,Sections 75S0S,25533 and 75534.1
understand that lithe building does non currently have a tenant,that it is my NEWRESIDENIIALMECH. SQ.FT - -
responsibllity to notify the occupant dthe requirements which must he met
pdortoi%uanmofaCertifia1co(00vpancy. - ( rXIwL 'R?(f
/' �/
Owner or autho dagent Date
TOTAL: ISSUED BY: VsjYll?1
OFFICE COPY