21883 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 21883
6► 3 C.
ere ams: one: q
OF CUPERTINO-BUILDING DIVISION `, _ ( c t
Go^ adorawme: Lie. APPLICATION I PERMIT �1 l 1
BUILDINGQ.ECTRICALFLUMBING-MECHANICAL CATEGORY CONTROL Is
Architect/Engineer: Lie.Nee
QTY ,.ELECTRIC PERMIT FEE •BUILDING PERMIT INFO
Address: PFRMITISSUANCE ❑ ❑ IU ❑
LICENSED CONTR under provisions
- PTIO
Ihth Syaffirm that I am licensod ion7OOO)o(DiAion3ofheBusirwlalndPmfhmsr9(rommenc APPLIANCES-RESIDENTIAL JOB DCSCRR'DON
then.I I.
force of Dlvfect. (the Bu.ineesandPro(nalona Cade,and my
Ilsnse Is his force and dlttY. PANELS l
License Ckm Lien f�Jrp re
Data Contractor a II l�
ARCHITECPS DECLARATION 701-1000 AMPS
q�u aO Zp l understand my plena shall be used u public records. OVER IOW AMPS -
SQ.Ff.FLOORARFA 5/SQ.Fi.
Fi o u Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDERDECLARATION SPECIALCIRCUIT/MTSC
Z t~a Fis7 I hereby affirm that T am exempt fromthe Contractor's License Law for the
po vI following reason.(Section 7031.5,Business and Professions Code:Any city or
O Z i. cmntywTEMP.METER OR POLE INST.
P� arydreture requires imicate,akorquireaer,improve,demoWh,orch mit to ,
neatructuretatemeits haaeegaiaorcdpursuanttotheProtheAppliCart mionsofte POWER DEVICES
01e a dgned statement that he k llcenaed incl and to the tion 7000) of the
3pG Contnctorb License Law(Chapter9(romnnncing with Section 700D)a(Dlvl- y �' 1
SWIMMING POOL ELECTRIC
sion3ofthe Busivesemd Prafeniow Code)orthat hekexem therefrommd VA UATION
< the bask for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not mum than
five drcddalkrth.pr. NEW RESIDENTIAL ELEGTR_SQ.FT. Spp ZIP TYPECONSTRUCTION
�n f,ae owner 9f the property,or my employees with wages as their sok / (`'.
f.. compenmHon,wlll dothe work structure k andlhe strucBot intended or offend for
"Fa4' sale(Sec 70K Business and Professions Code:The Contractors License Law
32 docs not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RIS.UNITS
who does such work himselforlhrough hlsown employees,provided that such
Improvements arc not intended or offered for sale.If,hcwevm the bu lld Ing or TOTAL:
Improvement is sold within one yearofcompletlon,the owner-builderwlll have
theta ed an of proving that he did not build or Improve for purpose of wk.). QTy, PLUMBING PERMIT ' FEE plppD ZONE APN
Lf I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEmntradon to mextrad the projed(Sec.7004,Busincm and Profeniow Code D
The Comracmre License Law does no apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
builds or Improves thereon, and who contracts for such ptojecla with a -
ogDlfaidor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
1_f I aLeaempt under . B k)�C1(or this reason BACK FLOW PROTECT.DEVICE OUTSIDE
1 �g 1 "nJm�-` DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y N_
LIS
Owner �� O PFAY Oats_Wa' RECEIPTIt
WORKMAN—CaOhea.erA�S certificate consent
1 N FX]`UREI,PER TRAP - SCIJOULTAX Y_ N_
cmf❑I hereby affirm that I have o Insurance
of consent to copy
sell-insure,ora REC=M
3800,lcateofWorken'Compensatloniwurance on certified ropy[hemof(Sec. GAS F.A.SYSTEM-)INCAOUTLETS
3800,tab C.I a Q PARK FEE Y_ N
Policy p - RECER?N
Com an GAS F.A.SYSl1M-OVFR4(FA)
� y BUILDING DI VISION FEES
Certlned ropy is hereby(umlahed. - GRFASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy k filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' IGREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WFr. Date Remi til
(Thissectionneed not be completed lithe permit k(prone hundred dollen D
(f103)rtifythat
J WATER HFATERW/VENT/E.ECTR ENERGYFEE Y N
(certify thatoy in an persnInanrformance tmnnerhe work for w tobcooh this permltri to the
I shall not employ any person In any manner a u to become abject to the >
Workere'Compensati^n[ansa of California, ATER SYSTEM/TREATING (la, Date - AID
O Z Applicant NEW RESIDGTITAL PLMB. SQ.FT. Date RCeel tN
Z 0 NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
Fshould become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
fA Code,you must forthwith comply with such provisions orthk permit shall be BUILDING
W y deemed revoked. FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaflim that then is a rowtruaton lending agency for the perform ELECTRIC FEE
UD ZanceoftheworkforwhkhthkperMtkLsaued(Sm3f197,Civ.C3 - TOTAL D ( ^O
O Lender.Name PLUMBING FEE
IL F Lender.Address QTY. MECHANICAL PERMIT ME MECHANICAL FEE
OU I certify that I have read lhkappllntknand atatethattheabove in(ormadon
(L Ica comod.Ixgree to complywhh all dtyand rounty ordinances and nate laws PERMITISSUANCE FEES PAID:
} N relating tobullding rowtrodlon,and hereby authorize representatives of this
F— Z city to enterupon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date DRecei I�
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
ug Inst liabilities,Ndgmena,miss and expenses which may In anywayaccwe AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: _P
u est mid City In ronsequen oft anting of this permit
AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
Slgnatureo pplant Lontnd r �zt EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building orovpart store or hand In hazardous HEATING UNIT(TO 100,000 BM
matedalm defined by the Cupertino Municipal Code,Chapter 9.12 and the Date RCt01 tit
I leallh and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: VD
❑Yea M No
Will the applicant or future building..part me equipment or devices VENDLATION FAN(SINGLE REED) ISSUIjifrk TEwhich emit hazard...air contaminants as defined by the Bay Area Air R''!U V
Quality Management Dktdct7 BOILER-COMP OHPOR 1000310 BTU) (�Q
(�
91 Yca No 199 1
avcrezd eafth&r pus materials reons255enkunderChapfer6.95 of NOILGR-COMP(OVlR 1fA,fX10 BTU) l3tNR Q
the California Health building Safety Code,Sections 7550.5,ve a t and 75536,I
understand that If nthfyteoupant of t e reenfly equirmnts which
that 11 met NEW RFSIDFeNTIAL MIiOi. SQ.Ff. ax{
responsibility prior
totciva to of notify occupant ofO the requirements which must be met Ci`,V! Cupertino
prior to Issuance ofa GtllRcate ofOnv panty. {r Y
Owner or authorized agent Date
TOTAL: ISSUED BY: 14
QIle KJNA.
OFFICE COPY