21348 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed ldentif catlon
BuildingAddress: �\0 PIO2MITN21 348
�/P70 Aeht-� DWIelog- e
vectors /f!'s F-'G d yy6 o1«/(e/ CITY OF CUPERTINO-BUILDING DIVISION
co/nrtj5ado/e sine: ,r/ Lie.No: APPLICATION /PERMIT 77
-p6sv BUILDINGE.ECTRICAI.PLUMBING-MECHANICAL CATEGORY. CONTROL
Architect/Engineer. Lla No:
QTY ELECFRICPBRMIT TEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l em licensed under prcvWonsofChap1er9(rommenc APPIJANCFS-RESIDENLAL — JOB DESCRfPITON
ingwitIf...h I.fu 2000)alDlaffect olthc8ualneuandPro(eaaonaCode,andmy
[Llan Is in(u o d em la' ��...1 fi PANELS
Dans.CV `' Lie« oPG do
Data ConlndorUP TO 2DO ANUPS
ARCHITECPS DECLARATION 701-1000 AMPS
1+p?0 ZO I undersand my plan shall be used u public records OVER 1000 PS SQ.FT.FLOOR AREA S/SQ.FT.
E Lireneed I'rofeulonal SIGNS ELEC CAL
Q OWNER-BUILDER DECLARATION SPECIALCE2 T/MISC
Z„ y LherebyafOrmthatlam exempt from the Contracmr's License Law for the
p ❑ fo
� llowing reason.eisett n 7031.5,goal..and Profession.Code:An d or
K 2H2, county which requires a permR to conatmd,alter,Improve,demolish,Any
{LMP.MEMORPOLEINST.
' itm
O file a signed staten
anystmemro pdorm W L tance,alsorequirestheappliuntfor such perment that he Is licensed pursuant to the provisions of the POWER
��� Contractor.License law(Chapter 9(commencing with Section 7000)of DIN-
steel o(lhe Business and Pesfessim"Code)orthat he Is exempt therefromand SWIMMI G LELECTRIC VALUATION
' the basis for the alleged exemption. Any violation of Section 70115 by any x
applicant fora permit subjects the applicant to a civil penalty of net more theR \ RTS HESEXTURES
$ five hundred dollars(SM. x •7 Q
I,as owner of the property,or my employee with wages as their sole R L ELECTR SQFG STOI TYI'ECONS7RUCT10N
compensation,will do the work and the structure is cart intended or offered for
O ssIs(Sec.7044,Bugneasand Professions Code:The Centract.e.License Law
$$ does not apply to an owner of property who Wilds or lerprovelhereon,and OCC.GROUP RFS.UNITS
who does suchwork himself or through his own employee.,proved that such
Improvementsamoot)ntendedoroffered forsals.I(howevegtim .11dingcr TOTAL:
ImpmvementOwldwlthinoneyearofcompietoMtheowner-Wlldei [base
ttlekurden of proving that he did not Wild or Improve for purposend .). P GING PERMIT FEE FlpODZONE APN
LJ L as owner of the property,am exclusively contracting with lim PIRMLI.
contractors to construct the project(Sec.70K Business and Professions Co -
TM Contnctor'e License Law dcee not apply to an owner of property wh AL D I &VENT-WATER(FA)
Wilds or Improves thereon,and who contracts for such p(ojem with
�ryBfador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sea B&P C for this re BA PROTECT.DEVICE
Owner Date D N OR ROOF,AREA,GONDSANITARY Y N. RECFPT
�- WORK MAN COMPENSATION DECLARATION PER TRAP ScliOOLTAX Y NN
hereby affirm that I have o re flimateInsurance
of convent to opyin.un,ora RFREBrT M
vitiate o(Worken'Compensationlnsurance oracertifLea ropythereof(Sec. GAS EA.SYSLEM-I INCA OUTLETS
loll'abc.)_l vC!?/497.003 rnI2x FEE . Y_ N-
- Comsn GAS EA.SYSTCM-OVER4(FA)
RECEIPTT N
Allied copy V herebytumBUILDING DIV
ISION FEES
sniffed ropy V(14d with thecity inspection division, GREASE/INDUSRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OFEXEMITION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFl. Date Recei
Qw
hisdion need net be completed lftM permit b(or one hundred dollen Pt# -
(S)00)orlar3 WATER HEATER W/VENT/ELFCTR ENERGYFEE Y N
[rent that in any Pa..inhe an thework an ast becomh this ermject to theed, —
I shall not employ any perwn in any manner at u to become subject to the /TREATING
Workers:Compensation tlon Laof California, ATER SYSTEM
. DatePAID
Z Z Applicant
Z p NOTICE TO APPLICANT:If,.her rtukl.g l his Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ1.7. Date Recei t#
Hshould become subject to the WorkerCompensation providers ofthe Labor TOTAL:
N Code,you mu at forthwith comply Mthsuch provisions mthls permit shall be B[�1 NG
W j deemed revoked. ErE
W
CONSTRUCTION LFNDINC AGENCY SEISMIC FEE
Z [hereby affirmthat there Lsacomtrodion lending agency 097,Cifor the perform TOTAL: ELECTRIC FEE
(,0 O ancoofthe workfor which thin perMtbl.wed(Sec.3097,CIv.C3 PLUMBING FEE
Ienderb Name
LL F Lender.Address QFY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mAllythat l have read this.ppEatlonandaamthattheaboveleformation
a Is cored.l dipme to comply with all city and county ordinances and gate law. PERMIT ISSUANCE FEE PPAID:
W relating to building mastmdion,and hereby authorize representatives ofthls -
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P[#
against litle.,judgments,rogsand ex sn which ma yinsnywayacerus AIR HANDLING UNIT ITO 10,000CFM) SUBTOTAL:
.gains City ron.glypaax c gof this permlt�
/�1J ./� NRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigret esof Appllant/Contrail r /Dta EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllitheappllans or furore building occupant st.m.r handle hazardous HEATING UNIT CM IOO,000 BTU) Date Recei f#
material as defined by the Cupertino Municipal Code,Chatter 9.17,and the -
Hrafth and Safety Co lVdion 75532(a)7 HEATING UNIT(OVER 100,000 BTQ
M Yea TOTAL•
No
Willtheappllcanto lure buildingompantuwequlpmentordevices VFN'IILATION FAN(SINGLE RESID) ISSUA X
whichernthazardous IrcontamimntsasdeBnedbythe Bay Area Air DECuality Mamgemcnl Dist
7 BOILER-COMP OIN OR 100,000 BTU) fd n
4Yes No
hYsreadlheM ou.materialsmqulmmenisunder Chapter6.95of BOILER-COMP(OVER IW,OWB ) IAM
the California Flealth Safety Code,Sedions75505,25533and2M34.I
under red that l(theCb�uilyding does not Curren haveatenan4thatitb my NEW AESIDENIIAI.MECH. YQ.PT. /K
Fp rue ility to ndif the occupant o(lher rrenta which muslt�/b/e�met
r to uancc of a c Pa /')_ /(/
64eror authodacd agent ----Data - -
TOTAL: ISSUED BY:
OFFICE COPY