21066 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21066
/of D .vL vF
nen a one: A
//>f` �S-7ya{y CITY OF CUPERTINOBUILDING DIVISION O
Contrctor
as Namr: Lie.No: APPLICATION /PERMIT 2S
—5Y LBUILDING.ELECTMCAI.PLUMBING-MECHAMCAL CATEGORY I C@NTFOL It
Arehitea/Engineer. Etc.No:
QTY ELECTRICPERMFP FEE BUILDING PERMIT INFO
Address
-� ❑LICENSED CONTRACFOR'S DECLARATION PERMITISSUANCE ❑ ❑ El
I hereby affirmthat lam licensed under provisions ofChapter9(commene- APPLIANCE-RESIDENTIAL JOB DFSCKB'TION
ingwlth Section 7DOO)ofDlvie=3.fthe Busineseand Pmfeselonscodgand my
liens,Klass l.rce and afect. PANELS S /
LlenseChm Lk.a
Date Contractor J
ARCHITECT'S DECLARATION XII-1000AMPS
a0 O I understand my plans shall be used u public record& OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ.Ff.
E o Licensed Professional SIGNSELECTRICAL
<<�¢ OWNER-BUILDER DECLARATION SPFCIALCIRCUIT/MLSC
71., IhercbyafRrmthat lamexempt from the Contractor's License law for the
62H following reason.(Section 7031 S,Business arad Professions Code:Any city or TGMP.MEI'CR OR POLE INST.
P countywhichmquimsapermittommtmd,allepimpmve,dem.lfah,orrepair
I anystructure prlorto its Lwrance,abaerequbesthe applicant forsuch permit to
5 Ills a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3Oyct
Contraor'sLicense/aw(Chapter9(commencing with Section 7000)of Dlvl-
slrn3of the Business and ProlcalonsCode)orthat hebexemptthemfmmand SWIMMING POOL ELECTRIC VALUATION
Gthe basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
for a permit subjectsthe applicant to a civil penalty of sea more than
o fi hunit ddoIt ($500). '
L ase"'o aof m m NEW RESIDENTIAL ELECTR_—SQFr. STORIES 7YI'E CONSTRUCTION
2 property,or my employees with wages es their sole
rom nsatl.nwlltdo Ne work and the strucWm is net intended or offeredfor
qsale(Src.7044,Business and Pmfasslom Code:The Contractors Llcerue Law
does not apply to an owner of property who builds or Improves thereon,and _ OCC.GROUP RIS.UNITS
CC.• who donsuchwork hlmsaforthicugh Msownemployees,provided that such
Improvements are not intended mattered formle.If,however,thebuilding or TOTAL,.
improvement is sold within oneymrof completim,the owner-bullderwill have
the4olen of proving that he did not build or improve for purpose of Asia.). QTY, PLUMBING PERMIT ---- APN
U L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7614,Business a ni Imfemions Code: PERMIT ISSUANCE
The Contractor's License Use does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Imro
pves thereon,and who contracts for such ptojects with e
Tcoor(s)Deand pursuant to the Contractors License Law. BACK HAWPROTLCT.DEVICE FEE SUMMARY
LJ I am exempt under Sm B k P C for this reason
DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N
OIITqlnV FEES
OwneDate RFLER'f N
WORKMAN MPkNS ION DELLA FDCIR(ES.PER TRAP SCl+OOLTAX Y N
11"t y affirm th have a ertiRrate of coneem t.el(-Insure,ore RECEIPT X
ceroicate ofWorkerf Compensation lreurance or a certified copy thereof(Sec. CAS EAI SYSITM•1 INC.40UILEfS
3800,Lab C.) PARK FEE Y— N_
PolCom an GAS EA.SYSTEM-OVER 4(EA) RECEIPT#
Y BUILDING DI VISION FEES
Certified copy at heed with the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CertBled copy V filed with 1M sly Inspection division.
CERTIFICATE OF FO(E,IPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE
(fhlssection need net becomplaed lithe permit lsforom hundred dollars SEWER-SANITARY-STORM EA.XIOP(. Date Remi tit
($1 I mutify thIn at
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll not that employ
an person.anynce of manhe ner au As t cern eesubjecmit Is Issued,othe —
t shall not employ any person f any manner w u to become subject to the WATER SYSTEM/TREATINC
Workers'Compensation(awe o(Gllf.mla.Date PAID
Z Applicant
ZO NOTICE TO APPLICANT.If,after making this Certlticate of Eaem)Hlon,you NEW RESIDENTIAL Pf.MB._SQ.F(. Date Remi IN
shwid become subject to the Workers'Compensation provisions of th.Labor TOTAL:
N Code,you must forthwith comply with such provbiomu crisis permit shall be
> deemed revoked. BUILDING
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE ^
Il Ihereby affirm that them is a construction lending agency forthe perform- ELECTRIC FEE
euaJ
Z anof the work for which this permit E,haed(Sm.3097,Cie.C.) TOTAL:
(� O Leader'.Name PLUMBING FEE
LL F- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ienl(y that l have read this application end state that the above Information
bmrreci.I dgrre,to comply with all city and county ordinances and state laws PERMTTLSSUANCE FEES PAID:
7• n' relating to building commuction,and hereby authorize representatives ofthb
(— Z city to enter upon the abovo-mentkmed property for Inspection purposes. ALTER OR ADD TO MECH. Dale Recei tN
_ (We)agree to saw,Indemnity an d keep harMess the City of Cupertino
Against liabNties,judgments,costs and expenses which may In any way accrue At R HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL,
aga Inst said City In rory
nauence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Signatu re of Applicant/Contractor Data EXHAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or future building oavpantet.re.,handle hazardous HEATING UNIT(TO 100,000 BTU) Date
material asdellmd bythe Cupertino Municipal Code,Chapter9JZ and the _ Reeel tN
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Rill
l lit No
111ook applicant turebuilding as defined
ndby tequipment he Bay Area Bevies VENTILATION FAN(SINGLE REBID) 1$�[�[AIQ(•p DATE
whichcookairrict? nlsm defined by the Bay Arca Air �sa"Ali yRP1
Quality Management District? BOILER-COMP ptiP OR 160,000 BTU)
4 Ye, E�OChaptersE� 51990
Mveread lotIth& oety Lode,Sections
255ntsunder .1 of BOILER-COMP 100,OlMl BTU)
tMerstand to Helih&Saf Code, otcurrntly have
a tenant,
d25hat it
understand that bility to notify
the occupant of
of t erequirments which
that itlsmy NEW RESIDENTIAL MECH. SQ.Ff.
rexpotuleauanxofaCtheoateof .(t he requirementswslch moat be nM - � n
polo issuance aaCertificate of Occupancy. SS
as �d
neroraulhorl d � rat
Data
TOTAL: ISSUED �v
OFFICE COPY