21721 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building/.dd reas: I
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wrens a one: A
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/- DIVISION
.
C APPLICATION / PERMIT
r /BUiLDING-ELECTRICAL PLUMBING-MECHAMCAL CATEGORY CONTROL N
Itect/ ase( �
c QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
I'FTtMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(cvrunme APPLIANCFSRESIDENTTAL ]OB DFSCRB'1TON
Ingwith Eect ofDi"slon3ofthe BuslnessandPro i.e.Codgandmy
Licenla In(uB to and sic. ^ ��C-%� PANELS �� r -
Llceseisine LIc.N
AMPS
Date Contractor UPT0200ANTS
ARCHITECT'S DECLARATION
Rj
NO O I understand my phn shall be used es public records. OVER 1000 AMPS �.FT.FLOOR f/SQ.FT.
Licensed Professional f SIGNSELECTRICAL
<<DiOWNER-BUILDER DECLARATION�n DiBPPLIAL CIRCUIT/MI9C
t., 7 Thereby a(flrnthat lam exempt lromthe Cont racterb Llansehwfor the
7V following reason.(Section 70315,Business and Professions Code:Any city or
Of.9 TEMP.METER OR IDLE INST.
F/. Y
M muntywhlch nqulresapemd[tocoraWct,alter,lmprove,dertnlbh,orrepair
�m anystructure prior to its bsuance,aleo requirestheapplicant for such permit to POWER DEVICES
K1 file a signed statement that he b licensed pursuant to the provisions of the
O . Contnctot'.Lu:,.Uw(Cha er9(commencin with Section 7000)of VALUATION
Q 3 p Fn B W NG R7OL ELECTIOC
slon3of the Buslnmmdl'rofexbsa Code)orthat he Vesem then/romand
'3 Q the basis for the alleged exemption. Any violation of Smile.7031.5 by any O E IRJI
applicantf.r.permlt.ubjed,theapplicantt..dvllpevltydnet.o thaa �/
E five hundred dollars MW. NE R 1
�r I,as owner of the property,or my employees with wages as their sole ff ift SIORIE9 TYPE ONSIRL'CTION
F compensation,will clothe work,andthetlntchre b not Intended or of(cmd for
Osale t,Sec. pX4,to an ower of property
who
W ilMConlranots Lerear hw
don asci apply to an ownerdproparty who Wlldsorlmprovntherron,and
DATEC—
o. whodon such work hlmxlforthrough hlsownemployeea,provided thatsuch `y OCC.GROUP RES UNITS
m
Improveents arc not Intended oroffered for sale.If,however thebullding or _
Improvement is sold within oneyearofcompletlon,the owner-bulldervetll have
tF,,jprdenof proving that M did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LI L as owner of the property,am ercluslvely contracting with licensed PERMITISSUANCE
contractors to construct the project(See.7M4,Business and Profesebro Code:
The Contractor's License Law does cot apply to an owner of property who ALTER-DRAIN4 VENT-WATER(EN
Wilds or Improves therme, and who contracts for such projects with• FEE SUMMARY
c,,ttLLlr,actorW licmrd pursuant t°the Contract.e.License Law. BACK FL
BACK DEVICE
LJ 1 am exempt under Sec. B& P C for thin reason
®
QIJTginr et-re
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N Owner Date RECFR'IN
WORKMAN COMPENSATION DECLARATION FIX.�Sp�.TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that I have certificate of consent to wre,ora RFLQPI'N
certificate of Workers Compewtlonlnunnce ora nnifled copy pyththemsf l5ec.
J800,his C.) GAS EA.SYSIfM-1 INCA OUTLETS PARKFEE Y N
I'oI1gN���r� ,�? GAS EA.SYSTQd-OVER4(EA) RERGDIX
Cent anv Yi/�/ !•_ BUILDING DI VISION FEES
Certified copy Is heehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy b fileded with with the city Inspection division.
CERTIFICATE OF UEEMMON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFRSANITAItY-STORM FA.1Wirf. DaIC RCOCI t#
IThls section need not be completed if the perrrdt Is forom hundred dollars
(locEorles•.) ENERGY PGE Y N
I certify that In the perform
anm ofthe work forwldch this permit is hawed, WATER FIEATER W/VIM/ELDCTR
I alall not employ any person I^any manner so as to become subject to the WATER SYSTai/,I-RFA,RNG
Workeri Compematlon hove o(Gllfornla.Date PAID
O Z NOTICnt NEW RESIDENTIAL PLMB. SQ_FT. Date Recei t#
Z 0 NOApplicant MPLICANT:It,ager making this Certificate of e=n,y..
Hshould bemmeaubject to the Workers'Compensation provlslon ofthe Labor TOTAL:
CC W Code,you most fort hwith comply with such provisions or this permit shall be BUILDING FEE
W deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihcmbyaffirtnthat thenhacomwctlon lendingagency for the per(orrry ELECTRIC FEE.
7 Z ance°fthcworkforwhlchthbp colt is issued CS c.3097,CIv.C.) TOTAL: _ r
02 Lender's Name PLUMBING FEE
LL h Lead.e.Address I r` QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ^
O W I certify that]have mad this. eatethat callon and sttheabovelaformatlon
incorrect.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE$ A
} N relating to building construction,and thereby authonau representatives ofthls �'4' j
F city to enter upon the abovcmenHoned property for inspection purposes. ALTERORADDTOMECH.
Z
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReCel P(#
against liabilities,pd,maid,coxa and expenses which may I.a^ywayamue AIR IIANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in conseque�of the granting of thisIt
I h i Ira p"N ti l AIR HANDWNGUNIT OVFA10,000C M) CONSTRUCTION TAX
Sigratureo!l� plicant/eentracto Date D(HAUSTFIOOD(W/DUCT) C %TION T4X PND:
HAZARDOUS FATF.RIALSDISCLOS E 9 O ebj
Will theapplicant or future building p..t store or handle h.rdous HEATING UNIT(TO 100,000 BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
I lealth and SafetyCade Section 25S31(a)i HFATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes 11 No
Will the applicant or future building occupant use equipman erdevicn VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which trait hazardous air contaminants as defined by the Bay Area Air -
Quality Management District? BOILFR-COMP OHP OR 100,0(U BTU) P.A10
Yes
have mad the haz2.NoNoaratcna.nqulmments under Chapter 6.95 of BOILER-COMP(OVER100,000 BT U)
the California llealth&Safety Code,Sectiom 25505,25533 and 25534. 1 SEB 1 1991
understand that lithe building does not currently haveatenanl that It is my NT.WRFSIDENIIALMECH. SQ.FT
responsibility to natty the occupant of the requirements which most be met P
prior to issu.ace of.Certificate of Occv p.ncy C"v 44 0.",Avner or auth ud agent TOTAL
Date ISSUED BY�
OFFICE COPY