21743APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pniect WentlflcatlonPERMITNIT
Liu— �Cy
Building Address: �J J
� �y �t_0U-,- e.11L P I e nL c�.:�
NO.
21.743
re arse. �� one:
A A
pRin
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGLLECTRICAL-PLUMBING-MECHAMCAL
tract..N.N.:
71"
CATEGORY
CONTROL N
ItcR/ glare LI
cl 12.NYS
lZe
- An v `
Q7Y ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am 11crosed under pmveslonsof Chapter 9(commrn
IngwlthSMion7")of DMsicn3ofthe Buslneaand PmfnsioneCade,and my
licLicnx lctass toraeanaLlceffeY.
Date Contnaor��� �/�
APPLIANCESRFSIDENTIAL
JOB DESCR11111ON
U
PANELS
701-1000 AMPS
ARCHITECTS DECLARATION
I understand my plaru shall be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREAA,
S/SQ. FT.
SIQNSELECTRICALl/�
Licensed Professional
—z5e�
SPECIALCIRCUIT/M19C
OWNER -BUILDER DECLARATION
IhembyafRrmthatfamexempt fromthe Comment.LicenseLawforthe
following reason. (ScR1on7031.5,Buslnessanl Pmfessione Code:Anyciy.,
muntywhlch mqulrn a permit tocopetma, alter, bnprove, derm0+h orrepalr
,
�y
/O {y [n[(%.
TEMP METER OR POLE INST.
anystrucwm prserto ltd Issuance, also requlrestheapplicant forsuch permit to
file a signed statement that he is licensed pursuant to the provislope of the
POWER DEVICES
SWIhfAUNG POOL ELECTRIC
OUTLEISSWITCHE .FIXMRES
Contactors License Law (Chapter 9(comrrcncing with Section 7000) of Divi-
slon3 ofthe Rusinessand Profenbpe Code) orthat he b exemptthernfromand
the bsais for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the a pplleant to a civil penalty of art more t ban
/y VA///LUATION
NEW RESIDENTIAL ELEC
live hundred dollars CiW.
❑ 1, as owner of the property, or my employees with wager as their sole
-
S I
TTq
TYPE CONSTRUCTION
compensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7011, Business and Profession Code: The Contractors License Law
does not apply to an owner of property who Wilds or Impresses thereon, and
who don such work himself or through Itis own employees, provided! t hat such
tmprovemcnn am not Intended oroffered for ale. If, however, thebullding or
improvement haold within oneyearofcompletlon,the owner-bullderwlll have
C 0 IVIC
TAL:
UP
/.)p
7J
RFS UNITS
tht, rdcn of proving that he did not build or Improve f¢ purpose of ale.).
LJ 1, a owner tr the Property, am exclusively Business
contracting with Code:
construct the project Code:
toces
Business and Iof
QTY. _ PLUMBI -ERMIT
Dao
aped .
PFRMITISSUANCE
TheconCommenrs pralope
License
License raw don not apply tct an owner d property who
not apply
The Coor Impresses
builds or Improv thereon, and who contracts for such pojMs with a
ctor(ssed pursuant to the emtndori License Law.
exempt
Ifam xept under Sm. B 4 P C for this reasson
ALTER -DRAIN 4 VENT' WATER ff.V
FEE SUMMARY
BACK FLOW PROTFLT.DEVICE
OUTS I DE FEES
DRAINS A, FLOOR, ROOF, AREGOND.
SANITARY Y N_
BBC= N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a ¢rtlfkate of consent to selbinsure, ora
certlflateofWorken'Comperaatlon Insurance., certified copytherea&c.
3800, Iab C.)
FIX. FS O'ER TRAP
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. INC.40ITILETS
PARX FEE Y N
policy N
RFJN
GAS EA. SYSTEM-0VER 4 (EA)
Comanv vis s-tD Is'L.
DT
LINING
BUILDING DIVISION FEES
�Certlfled copy is berebyth the cityed.
�j Certi(I<d copy Is filed with the city Irupettlon dlvlsion.
GREASE/INDUSTRL WASTE INTFRCFPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SpWER.SANTTARY-STORM EA. 7WFT.
COMPENSATIONINSURANCE
(Thlssenion need notMENSA thepermit Is(.tone hundred dollars
Date RCOCI t#
WATER I -LISTER W/VENT/MVrTR
ENERGY FEE Y N
PAID
Cit I0)oifyth pesubjec Issued,
]certify that employ
1 shall not employ any person in any manner so v to become subject to the
anyhe pfo on In an the work as to become
Workcn'Compensatlon laws o/GIl(.rnla. Date
WA1Et SYgrEM/TREATING
Appliin
NOTICE
NOTICETOMPLICAtot a after nuking pe sationCertifpreof Exemption, you
shouldou=a innorni, to the Workers' Compensation per the Labor
Date Rtsmi ted
NEW RESIDENTIAL PLMB. SD.Ff.
TOTAL:
forth
Coda you must forthwith comply with such provIsloa or 1hIs permit shall be
.,this
deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LF]VDING AGENCY
I hereby affirm that them is a copetmctlon lending agency for the perform
ance.f the work for which this permit. 97, ed(Sec. 30Civ. C.)
TOTAL:
ELECTRIC FEE
lander. Name a
Lender'.Addm'_
I certify thatl have mad thisappli tonand slatethat theabovelnformation
is correct.I agree to complywlth all city and county ordinances and gate laws
¢l.ing to building construRlon,and hereby authorim reprexntatives of this
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES FAIR:
6
m0
city to enter upon the above-enoned property for Inspection purposes.
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
ALTERORADDTOMFCH.
+I -_p
ate Receipt#
SUBTOTAL:
against liabilities, pdgmente, cussand expenses which may In anywayamrue
.posatald City in mnspuentt the grantin ofthlapennit.
(�'ar
lDate
AIR HANDLING UNIT(TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,(DO CFM)
CONSTRUCTION TAX
Signature of App nt/Contract¢
HZWOUSMATERIAL. ISCLOSURE
EXHAUSTHODD(W/DUCT)
CONSTRUCTION TAX PAID:
L+5,6
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future building omv ntstoreorhandlehaaardous
rogerhlascieflned bytha Cupertino MuN pal Coda Chapter 9.17, and the
IleaRhand Safety Code Section 7 374)7
❑ Ye. �] No
_�1�
Date RCCeI t#
HEATING UMT(OVER 300,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESOD)
ISSUANCE DATE
- Wlllthe.pplicant or future building omvpantuse equipment ordeviae
which emit harardous air contaminants m defined by the Bay Area Air
BOILERCDMP OHP OR 100,(X0 BTU)
Quality Management Dottier?
Yes 1� o
have read the h.2Nmaterials requirements u oder Cha pier 6.95 of
the Cali/.rola HealthhSafety Code,S iope75505,75533and7558.I
FEB 1 a �ggl
BOILER-COMP(OVER 100,000 BTU)
I NEW RESIDENTIAL MECH. SQ.FT.
understand that ifthebuildingelon not currently have. tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
to Issuance of a Certificate of 0cmnay pa
t —z e y,
Ownerorautho - agent Date
dry, 0",prior
ldla
ISSUE D BY";"
TOTAL:
OFFICE COPY