21748 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
r Building Addresr
-'/ 7. Pi„lt 82ovle 46r Na) /'� /- r 21748_
er. me.. �_ we A A A
reooruOrouo. 141c . CITY OF CUPERTINO-BUILDING DIVISION
ntrad rNh L APPLICATION /PERMIT �. 7/
C' BUILDINGELPGTRICALPLUMBINGMFGI-IANICAL CATEGORY CONTROL N
tl/usginmr. LI
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adore.,
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I Mrebyafflrmthat lam licensed under prevblonsol Chapter9(commmc. APPLIANCESRESIDENHAL JOB DESCRIPTION
ingwlth SectW.7000)of Dihtid.O ofthe Businessaod PmfesslonsCode,and my
license la In v8�esnd PANELS
LicenseLe.0 lY
W' J
Date Cmuracter UP TO 2DO AMM
ARCHITECTS DECLARATION 201-1000 AMPS
WOz UZ I understand my plans shall be used u publlcrecords. OVER 1000 AMPS SQ.R.FLOOR AREA $/SQ.FT.
qq�++ CO
k Licensed Professional SIGNSELEGTRICAL
<<�<&I OWNER-BUILDER DECLARATION SI'[CIALCItCUIT/MIST ��SIS .sY•r].
7 f,aX I hereby affrrmthat l am exempt fromthe Contractor's Llanxlawforthe
following reason.(Section 9m1.5,Business and Professions Code Any city or
O�E'u9 noun which Irma permit to construct,alter,lmrepairTEMP.METER OR IDLE INST. (G'U
tm rtyu pe provedennlbh,or
any at mctunpriorto entaissia hathe is aim reed inns the pursuant t the revisionsor such permitoo POWER DEVICES
ryL 4 U to
lice a algned statement that M to Enter licensed ed pursuant to the tion 70ons f the
Con3ofthausem swr.(e.i9(mmmenctat heel Sempttherefomand
O rnSWPdMING IX30L ELECTRIC
1.., sb basis fo Butlnev and Prdmsion. Any)od.tion f exempt theufmy any ALUATION
Q Y.'S the bask for the alleged exemption..p Any violation of Section 9m1.5 by any OUTLETS MHFSFIXTURES C
five undred apelars CS jecta the applkant toot tivli penalty ofnot more thin
c.q .flue hundred dollars IS+00).
NEW RESIDENTIAL ELECTR �,FT.
jf? I,a owner ) the property,or my employees with wage as offered
cele SCOW 65 ECON'SIkIKTION
comNn
.1.(Sesa 0K Business w Protea ma;CodunheC.utacto?o License
eLaw
p vie(Sec.70K to Businessand
property Code:The Contractor's Llcaae law
$ docs netapplytorn owner ofp rough iswho Wild.
mpoyme,primproves tMrmnuch
who docswchwork himse8orthrasgh hlaown emplgm,pmvided that sucF OCC.CROUP AES.UNHS
Improvements are not Intended or offered for sale.If,hmveveq the building or TOTAL_
Improvement Is sold within oneyearofcomple irm,the owner-builderwill have
t rd en of proving that he did not wild or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE
FLOOD ZONE APN
4 as owner t the property,am cu44,ivelyBusiness
contraess andProing with Is ensedCode; PERMIT ISSUANCE
contradon to cowwct the w doe(Sec.ot appl euslnese and Professions property
Code:
W2- -1
thalaw does who
pplyet an owner pppce.wwho ALTER-DRAIN -WATER ffN
W Irh'Ws t impcovn thereon,and who mmrtm for such w.OFcn with a
ry0tI Oo exempt Pursuant to the Contactor.Llrtn:Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLAW PROTOCT.DEVICE
Owner ate
DRAINS R D. SANITARY Y_ N_
DRECEIPT N
WORKMAN COMPENSATION DECLARATION EIXNRESI O TAX Y_ N
❑1 hereby affirm that I have a certificate of consent to self-Ineum,ora RECEIPT N
oertiflate olWorken'Compersatlonlvurana ora rtrtlfled cop/thennf 6ec. G�IX _i 4 gK Y N
3800,Lab CJ
polity NRECEIPT N
Com anv [i i GAS EA.S (EA) BUILDING DIVISION FEES
�Certlfled copy b hereby furnished.
�Cedl(led copy V filed with ted city Iropecttan dlvLion. GREASE/LhDUSIRL WASTE I CHECK FEE
CGRTIPICATEOFENLMITIONFROM WORKERS' GREASE TRAP PAID 5a
COMPENSATION INSURANCEyEysp,R-SANITARY-SIORMEA 200FT Date Recei IN
(Ihl.sedbn need not M completed 11 tM permit is far one hundred r
dolla
(S100)orlea3 WATERHEATFRW/VENT/ELECTR ENERGY FEE Y N
I cartifynot that o the performance of the work so as to
this permit c boned,
I shall not employ any perms In any manner m u to become vb)ect to the WATFRSYSIFM/TREATING
Worken'Compemtlon laws of California.Dose PAID
O Z Applicant NEW RESIDENTIAL?LMB. SQbT. Date Recei t#
Z O NONCE TO APPLICANT.It,after ma king this Certificate of Exemption,you F should become mb}at to the Workeri Compevation provisions of the Labor TOTAL:
jW Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE -�
deemed revoked.
d 011
C CONSTRUCTION LENDING AGENCY SEISMIC FEE 3. .
Iherebyalfrork(rmthat then b a construction lendi^gagenry forth perform ELECTRIC FEE
Z ance.fthe wcar which this permit boved lt5m.3097,CIv.C.) TOTAL:
() O Model.Name r t 1 ePLUMBING FEE
LL H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedifythat l hhb
ay.mad tapp ttonaod stainthat the above Information
M bmrnct.i.grcotocomplywith.Udtyandmuntyordinanmandrtatelawa PERMIT ISSUANCE FE S AI :
)- relating to building cerstwdlon,and hereby authurize representatives of this
F city to enter upon the abinspectionove-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z to Date RCcel tN
V a wtlbb�ea,save nn s mrsand keep harmless the City of Cupedlno P
Ba Y g penseswhich emyln anywayacems AIR HANDLING UNIT(70 10,000 CFM) SUBTOTAL:
�
against mid Ci in consequence of the granting of thlsp¢rmit,
M
(x1M I ARHANDLNGUTOVFR10,000CR 1 CONSTRUCTION TAX
laR aL
SlgnatumofA �CO-^SrT�-/r-r—CTION T^X
PAID:
IXIiAUST HOOD(W/D1CT)
HAARDOUS MATERIALS DISCLO RE 4wfs_
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date Recai IM
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the
Health and Safety Cade Section 25532(x)? HEATING UNIT(OVER 10,000 BTU) TOTAL•
M Ya. M No
Wel the applicant orfutum wilding occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haardom air cents mlrunts as defined by the Bay Arta Air
1 Quality Management District? - BOILER-COMP OHP OR 100,000 BTU) Nua
No
Thavereadthehaa. lus materials rryumments under Chapter 6.95 of BOILERCVMP(OVER 100,000 BTU,
the California Health&Ssfety Coda Sections 2550.5,25513 and 25534. 1 FES 1'41991
understandthat ifthe building don not evruntly have atenanL that ltbmy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the ocxvpart of the requirements which must be met
prior to issuanceof a Certificate of Occupancy. A.4. /1lsr�• 1
..� ,I ,I� I VIED —
OwnerorautM10 cad agent to ISSUEDBY:
TOTAL: -
OFFICE COPY