21326APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
nulldin Project Identification
Building Address:
S (4. n�lCC Lqn�
PERMITNO.
21326
wnera arse: one:
Ga�L, 4P iry,m ��%'�--i Sj
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBINC-MECHANICAL
A A
d— �� �b
C (trade •Name° I Lm. Na:
-'pro a G� � QO ��� �` 11ly,7
CATEGORY CONTROLY
Amhited/Engineer. Lie. Nee
QT4 ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addres>
® El El 1:1
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby a/fren that l am licensed under provisions of Chapter 9(commmo-
Ingwlth Sedi..7000)ol Di Wt i..3ofthe Bustumand Pmlesslon,Code, and my
Ilcen, le Inn a and iiced. 11 k iQ %
L-Imn . ss Llc. p
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
G
PANELS
Date oil Conrado, 1� rarH�—
201-IODOAMIaS if 1
ARCHITECPS DECLARATION
I understand my plansshaB be used as publierecords.
OVERIODOAMPS 11 1
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Pmlesebral
-
OWNER -BUILDER DECLARATIONLCIRCN
I herebyaffim that am exempt from the Contractor's Licanrt Law fee the
folloywhich quimdperrrdtt.c. ]nem andr,i emiona Cock Any tltyoa,
countywhlch requlresa permit loconstvct, ateny Improve, demtjllsh,orrepdi
anystmdum paortoita lsmame, alas requireathe appllcantlorauch Peront to
file a signed statement that he la licensed pursuant to the p`eovbbns of the
Contractor's License Law (Chapter 9(mmmeneleg with Section 7DOO) of Divi-
knoll Of the Business and Profeehme Code).,that he is exempt therefroneant
SPECIArc67/M1SC
�. TEMP.MEIFRORPO (NST
POWER DEVI 5'
r
SWIMMING POOL ELECTRIC
VALUATION
the bash for the alleged exemption. Any Wolatlon of Section 70715 by any.
applicant fora permit subjedalhe applicant to a civil penalty of.6t more than
0ve,hundrad dollars BSDO). II/
M 1, a owner of the property, or my employes with wages as their sole
OUTLETS -SWITCHES FIXTUR�
-
1100,06
NEW R FNIIAL ELEM SQFT.
STORIES
TYPE CONSTRUCTION
compensation, willdo the work, and the structure is not Intended or offered for
sale (Sec 7016, Business and Professions Code: The Contractors Lt... Taw
-
does out apply toanowner efproperty who builds orImproves thereoe,and
whodoesauchworkhimselfarthrough hisownemployeesprovided thatmch
OCC. GROUT'
RES. UNITS
Improvements are not Intended oroffered for sale. If, however, thebuilding or
Improvement b sold within one ynarof compidiom the owner-bellderwill have
the burden of proving that he did net build or Improve for purpose of axle.).
M L as owner of the property, am exclusively contracting with licensed
contractors to construct the projectt(Sec- 7064, Buslnemand Pra(esslom Code:
The Contvdora License Law den not apply to an owner of property who
Wild. or Improves theme., and who mmrads for such joeJects with a
dor(.) Beenxd pursuant to the Conrado,¢License Law.
cgR¢aso
1 am exempt under See B k P C for this rean
TOTAL:
PLUMBING PERMIT FEE
QTY,
PERMIT ISSUANCE
ALTAR -DRAIN kVENT- WATER (FA)
FLOODZDNE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N
RECKIn N
Owner Data
WORKMAN COMP[NSATION DECLARATION
01hereby affirm that I have • esdtficate of consent to self
SCHOOL TAX Y_ N-
-Insure, or a
mdilicateolWorkere Compensatl.nlnsumna.racertl(Ied mpythereof (Sec.
3800, Lab C.) '
Pollry Y p c. 4 yG rl L a
AECEIIPI'M
GAS A.SYSTEM-1 WC.4OUTLETS
PARK FEE Y N
RECEIPT N
Com anv _GAJ cue. Inn l_
MCertlfled mpy filed the ad
❑Ccrtllled ropy V filed with the dty Inspection division.
city
GAS- EA. SYSTEM -OVER 4(EA)
BUI LDING DI VISION FEES
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GRFASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANC
COMPENSATIONE
(Thlssoctlen need nut be If the permit isfor one hundred dollarsSEWRR.SANITAAY-STORM
($100)oify that
In this rmit cbo theed,
Ill ort thatoy any eraminanance tmwner so as; to bcome, subject
I shall not employ any person In any manner m m to becorre mbjed to the
Workers' Compenmtion Tawe o(GII(.mla. Dale
PAID
Date Remi t#
FA. IWFr.
WATER HEATER W/VENT/ELFLTR
ENERGYFEE Y N —
PAID
WATER SYSTEM/TREATING
ApplIcaNOTICE
NOTICE co APPLICANT: a after making this Certificate of Exemption, you
should become aub}xY m the Worken'Compenvtlon previsions of the Labor
Code, you most forthwith comply with such provisionsm this pemrdt shall be
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB, SQYF.
TOTAL:
NG
Cot
TOTAL:
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
!hereby a(firmthat there la a construction lending agency for the perform
ance of the work for which thin permit Is Issued (Sec. 3097, Clv. CJ
ELECTRIC FEE
L mdee. Nance
Lcndae. Address
Imdlfythatlhavereadthlaapplicatlnnand Aatethaitheabovemlor tion
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FBG
'
FEES PAID:
inrommt. l agree to comply with all city and county ordle.occe.ed state lam
PERMITISSUANCE
relding to building construdi.n, and hereby autherire represeniatWea c f this
city toenterupon the above-mentioned property for inspection purposes,
Me) agree to save, Indemnify an d keep harmless the City of Cupertino
agametllabllthes, pdgments, mac and expenses which mayln anywayamem
agaun Itfes� d City in son enc¢ of the grantiRg of this permit.
ALTERORADDTOMECH.
AIR HANDLING UNIT CTO 10,ODOCFM)
Date Recei t#
P
SUBTOTAL:
AIR HANDWNGUNIT (OVER l0,000CFM)
CONSTRUCTION TAX
Sigmmre'of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupantatore or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.IZ, and the
Health and Safety Cmc Ion 75532(.)7
F1s�
Yes �o
Date Recei t#
I MATING UNIT (OVER 100,000 BTI!)
TOTAL'
_
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant orfuture building occupant use equipment ordevices
which cont hazardous air coniummarde as deflated by the Bay Area Air
BOILER -COMP C311POR 100,001] BTU)
Quality Management Dl d7
Ycs No
�p�
BOILER-COMP(OVER 100,000 BTU)
aza
have neadtheboua materials requirements under Chapter 6.95 of
the Glif.nda Health k Safety Code, SMions 75505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that It 6 my
v�:Ka
//�v o
EJy �y 4 1gprT
NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
QJJll44
prior uancc o(a dificatc ofOttvpanry.
Hazy q _
Owner or authorized agent Date
�, ®
ISSUED BY:
TOTAL:
OFFICE COPY