21747 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruudin Project Identification - PERMIT NO.
Bullding Add.,: L_ci _) � 21747
era ame: Phone. _ w A A
CITY OF CUPERTINO-BUILDING DIVISION
tray r',Na : APPLICATION I PERMIT 1 — L— G
7, CATEGORY CONTROL a
Iced BUILDINGElECTRICALIrLIMBINGMECHAMCAL
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QTY ELECTRIC PERMIT FEE FIX PERMIT INFO
Address, ' PERMITISSUANCE JC I
LICENSEDCONTRACTOR'SDECLARATION �\ 41 I�
I here's ffirre that l am licensed under provisions of Cha erg comment, APPLIANCFSRESIDENTIAL
Ya P Pt ( JOB DFSCRD'ITON
Ingwei-in fan 7000)of DI effect o(1he0uslnevand ProfesslonsCade,anal my �
license b in fv0 fo and died. e 6m y PANES �� I ,"�
LicenseCla�__ mntr //Y w
Date Contractor '
ARCHITECTS DECLARATION 201-1000 AMPS
�7. I understand my plans shag be used as public records. OVERI"AMPS SQ.FT.FLOOR AREA $/SQ"Fr.
O
ZLicensed Pmfesslonal SIGNS ELECTRICAL
G OWNER-BUILDER DECLARATION ry L�5 ,
I�n SPECIALCIRCUIT/MISC �W/ J
ZF. a owinrby asirmthatlameve5,Busimthe Contractor's License Law for the ' ✓✓✓"'
p following reuon.f$enters 7001.5,Buslnm and Pm(esalovs Code:Anytlty or I — // �'
OZF. TEMP METER OR POLE INST. (�(/.`a//)^] .H
F� muntywhlch rtqulmapermit to mnstrud,alter,lmprove,demoLLsh,arrcpalr (/3 1
g anystmV mpdortoiblemancgalsortquimtheappBuntfonuchper tto POWER DEVICES
Li O file a signed statement that he Is licensed pursuant to the provisions of the Cr
bOSContractor's License Law(Chapter 9(commencing with Stolon 7000)of Divi- Aar,
slog 3ofthe Business and PrefesslonsCode)orthat he b exempt therefmmand SWIMMING POOL ELECTRIC
6 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7LETSSWITCFIESF[%7l1ftE5'
applicant fora permit subjects the applicant to a civil penalty of not mom than
c. o five hundred Bolton(5.500). NEW L
.. n 1,as owner of the property,or my employees with wages as their sole SIOWGS TYPE CONSTRUCTION
5 z compenation,will Bothe work and thestructure Is not Intended or offend for
F Ci sole(Sm.70N,Bwbuas and professioro Code:The Contractote Llrnnse Law
doesnotapply to an owner ofproperty who Wlldsor Improves thereon,and OCC.GROUP RES,UNITS
C: whodmsuchworkhinvelfmthmugh Msownemplgm,pmvidMthatsuch
improvements am not intended oroffered for sale.If,honeever,thebuilding or
improvementtssoldwithlnoneyearofcompldl n,theowner-bullderwlll Laave
th rdenof proving that hedld not Wlldorimproveforpurposeotsals.). QTY, P UMBING ERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See 7DK Business and professions Code:
The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN 4 VENT WATER(EA)
Wilds or Improves thereon, and who contracts for such p(ojeds with a
c,q➢➢ttrractor(,)licensed pursuant to the Coe dols License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSI D"FEES
DRAINS R,F OOROOF,AREA,CONT). SANITARY Y_ N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCIdOOLTAX Y_ N_
❑1 hereby affirm that I have• Ie rate of concent to pythson,ora RECFiPr N
MM,ab of Warken'Compensatlonlnsurance orarnrtlfled mpythereof l�['[. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3500,Lab C.I
Paltry M ACCID'T N
Com ansa \ N•f'rn9 rakJlC--•'`. GAS F.A.SYSTGf-OVERN(EA)
BUILDING DIVISION FEES
[Certified copy is hereby tumlMed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
[ECertif cd copy V filed with the city Inspection division.
CERTIFICATE OFi XF MON FROM WORKERS' GREASE TRAP PAID
COMPENSATION if INSURANCE SE'1VFA-SANITARY-STORM EA.700FT. Date Rceei t#
(rhos lesson need net W completed If the permit b far one hundred dollars
R1 rWATER HFATRW/VENT/=TR ENERGYFEE Y N
]certify that In the performance,ofthc work forwNch this permit is hsued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATT G
workers'Compensation Laws of Califorola.Date PAID
-
zZ Appllant NEWRESIDFNfIALPLMB. SQ.FT. Date Remi t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exempts nm you
Mould become subject to the Warlmn'Comperwt on provisbro of the Labor TOTAL:
~ W Code,you most forthwith comply wlth,uch provblons orthls permit shall be BUILDING FEE
deemed cooked.
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrm slut then V a construdlon Icndmg agency(cur the perform ELECTRIC FEE
Z anmoftheworkforwMchthbper ! /�d Sec.3097,Civ.CJ TOTAL:
00 Lenders Name_ N / e PLUMBING FEE
LL H lender'sAddm,_ / QTY. MECHANICAL PERMIT FEE MECHANICALFEE
I cenifylhat l havercad tho.ppItrationatiol Asethatthe above informative
O W
a iscomert.l agree to comply withal[city and county onllnanms and Hate laws PFRMITISSUANCE FE SD.
} rela0ngtobulldingmnstrvdion,.ndhenbyauthorlaempresentativmofthb
(— city to enter upon the abovememloned property for inspection purposes. ALTERORADDTOMDCFL
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertlna Da& Receipt#
against liabilities,judgment,mstsaed expenses which may lnanywayamrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In coe qu,nm of the granting of this permit.
AIR FIANDLING 11MT(OVF]t 10,000CFti) CONSTRUCTION TAX
Signature of AppBa Contractor Date EXHAUST HOOD(W/DUCT) CONST UCTION T?AX P ID:
HAZARDOUS MATERI SDISCLOSURE �JI)U� IQCJ-f'
Will theappllont or future building occupant store or handle hazardous HFATING UNIT OO 100,000 BTU) RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I Icabh and Sifety Cade Section 25537(A)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
❑ Yes ri No
Will the a ppllant or future building occupant use equipment or d evices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havnlou,air eonornlnant,as defined by the Bay Area Air
Quality Management Disttlwo
d7 BOILER-COMP OFD'OR 100,0(3 BTU) am
4hYes avereadthe h am materials requlrementsunder Chapter 6.95of BOILERCOMP(OVOim' 0BTU) F�
the California Health&Safety Code,Sodlons 25505,25533 and 75534. I =•
understand that lithe Wilding does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQI"r
responsibility to notify the occupant of the requirements which most be reel
prior to issuance d a Certificate of Occopanq•. r 7e
Owner or author' agent Date
TOTAL: ISSUE 17
OFFICE COPY