21273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
,Building Peeled Identification - PERMIT NO.
Building Address: Z /IO 77 a% J0 �, _ 21273
(JvmrYNme: ane: A
P P CITY OP CUPERTIN0.BUILDINGDIVISION 3 aQ
C tra 'e Ne LIc.No: APPLICATION / PERMIT
mN `�'/ Z BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY C NTA L 0
Architect/Engineer. /[d�C�.,a u�,nG� Lie.No:
,/ /]�� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:/ D 1 1330/✓ 1 j e% C O PERMITISSUANCE ITMB
LICENSED CONTRACTOR'S DECLARATION E
thereby affirm that l am licensed under provisions of Chapwr9(comme, APPLIANCES-RESIDENTIAL JOB DESCRB'fION
ingwith5 dio1nn77o0r0O)off DDlvlslon3ofthegusindaand ProfesslonsCpde,end my
Lrensseclaasu�Lic.# Ze� PAPIfIs t p
Dater 7J=_q_i Gantmcmr CN rnl�`� R�Aair
" P/ f/ ARCHITECTS DECLARATION 201-IO00AMPS /
re0 Z I understand my plans shag be used m public recards. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
U
O
rLZ Licensed Professumal SIGNSELECTRICAL
<< OWNER-BUILDER DECLARATION '
SPDCIALCIRCUIT/MISC
Za, Thereby affirm But lame from the Contractor's License Law far the
foVowing reason.(Section 70015,Business and Professions Code:Any city or
Ft't9 countywhlchrequU apertMttomnimc,aiter,impmve,den lbh,orrepair TIME.MFrER OR POLE INST.
A� anystmmmpr rtoitsbsuame aLsorequirestheapplluntforsuchper it. POWER DEVICES
file a alpin!statement that he is limned pursuant to the provisions of the
3 LLp fn Co '.ntactorLicense Law(Chapter9(mmmenclng with Section 7000)of Diet. SWIMMING POOL ELECTRIC
p, sion3 ofthe Budrem and Professtons Code)orthat he is exempt therefromand VALUATION
yd the basis for the alleged exemption. Any violation of Section 7031.5 by anyOUTLETSSWITCIiF
mm
O« applicant fora permit bjectathe applicant to a civil penalty of not ore than SHXTDRES.
five hundred dollars(5500).
z 6 nI,pe as owner the property,or my employees with weed as their dole NEW RESIDENTIAL ELECTR �'�' STOW ES TYPE CONSTRUCTION
mmpensatiory will lldo the wort,and the structure Is not Intended or of/eyed for
❑
sale(Sec.7066,Business and Professions Code:The Contradors Lldrue lawdo
does not apply to an owner of property who builds or improve%thereon,and
c. who does suchwork himself or through his own employees,provided that such OCC.GROUP RIS.UNITS
Improvements arenot Intended proffered formle.I(howevegthebuildingor TOTAL:
Improvement im ld within oneyeara(complelion,the owner-bu0lerwill have
thitburdenof proving that he did notbulld or Improve for purpose ofsale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively mntndlng with licensed PERMIT ISSUANCE
mntaconstruct to nsthe project(Sec.70K Business and Professions Code:
The Contractors License taw don not apply to an owner of property who ALTER-DRAIN&VENT•WATER[EA)
Wilda or improves thereon, and who contract, for such ptojects with r
,Lactor(s)licensed puuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
c LJrecant
am exempt under Sec. B Is P C for this mason
.Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑I hereby&fflan that 1 have a metiflate of consent to self-Inspp(gpRpg PER TRAP SCI{OOL TAX Y_ Nure,or RECEIPT M
mrtiflate,of Workers'Compereatlooldurance or a aBlfied mpythereof(Sec. CAS EA.SYSTEM-1 INCd OUTLETS
3#00,Lab CJ/ZZ/ZS//y�"/D PARK FEE RECEFr#
Comcyanv GAS�EA.SYSTEM-OVER4 BIA)
BUILDING DIVISION FEES
Certified copy Is hereby with
the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�faeRifled spy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID
Cot Wcom
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Reeei t#
Rhm ledlon need not be completed lithe permit b forone hundred dollare
(51WvailessJ WATER I RESTER W/VENT/EECTR ENERGY FEE Y N
I certify that o the performance any
m work so as to b this permit c booed,
I shall not employ any meson In any manner w d to become subject to the WATTR SYSTEM/TREATING
Worker%Compeneatlon Laws of GlifornIs.Date PAID
O Z Applicant
Z O NOTICETO APPLICANT:If,after making this CertlRate of Exemption,you NEW RESIDENTIAL PLMB. FO]T. Date Recei t#
should be..subject to the WorkerCompensation provisions of the Labor TOTAL:
CCN Cade,you must fort hwith comply with such provisions or this permit shall be
deemed revoked. 13VILDING FEE
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
thereby a(flrmtegei
hat there is a mwtructlon lending agency for the perform.
Z ance ofthe work!or which this permit is Issued(See.3097,Civ.CJ TOTAL: ELECTRIC FEE
-
V O Lenders Name PLUMBING FEE
IL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythatl havereadthb application and statethatthe above Information
IL is correct.Iagree tocomply with all city and county ordinances and date lam PERMIT ISSUANCE FEES PAID: �4
>. N relating to building construction,and hereby authorize representatives ofthis 3. J�
I• Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Dale ReCej [#
— (We)agree to save,IndemNfy an d keep harmless the City of Cu pert too P a
against liabilities,judgments,ends and expenses which may in any way accrue AIR HANDIJNC UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR]1ANDLING UNIT(OVER I(like CPU) CONSTRUCTION TAX
Sigrutum of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the app0ant orfum re building occupant store or handle hazardous HEATING UNIT(TO I OO,WO BTU) Date RCCeI [#
material as defined by the Cupertino Municipal Codi,Chapter 9.12,and the
ties lth and Safety Coda�+.�Section 23532(a)7 BEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes . u No a
Will the applicant orfutum Wilding occupant use equiprrcnt or devices VENTILATION FAN(SINGLE RESID) ISSURjh(d
which rout hazardous air motamlrants as defined by the Bay Arca Air
Qu Ifty Management DBWci7 BOILER-COMP OHPOR I00,OID BTU) f�
,g( Yea n❑No k1T['1•.A D
R have read the hazardous materials mquirements under Chapter 6.95 of BOILER-COMP(OVERI00,ODO BTU)• F
.�
the California Health A Safety Code,Sections 25505,25533 and 25536. i
understand that if the building does not currently ha veatenant,thatltbmy NEW RESIDENTIAL MECH. SQ.FT. asy, sa�(SU Td•w7
rdpm
ons Oi yto ndityth meant of the requirements which must be et yj�tll Si
seance ofd ficate o(Ompa
cr or authorized agent Data TOTAL ISSUED BY,
OFFICE COPY