21648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ing Address: 21648
Zr7y/ 5 wTA ��A ��9��
ante: one:
RT /y 12Y &&AM7?ra CITY OF CUPERTINO-BUILDING DIVISION
c° "°r' uc.N : APPLICATION I PERMIT - 1
OW' -7 H � ��" ; o BUILDINC-ELECTRICA MUMBINC-MECHANICAL CATEGORY CONTROL N
srchited/Engineer. Lic.No: '
QTY ELECTRICPERMFI" FEE
' BUILDING PERMITINFO
Add.
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE ❑ ❑ ❑
I hereby affirm that l am Licensed under provisions of Chapter9(mmmeno APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Divlaicn3 ofthe Buslnessand ProfesitnsCude,and my -
Licarce b in NII(° rad dfed. 1919PANELS
License Class Lk.Nkv
Date Con[ador
ARCHITECP ACLARA 701-1000 AMPS
�Z. I understand my plans shall be used as public remrcia. OVER1000AMPS SQ.FT.FLOOR AREA E/SQ.FE
CG 3o(3 Licensed Professional SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/1419C
z l-, Ihercbyaffimmthat I am exempt fromthe Contractor's License Law forthe
following reason.(Section 7031.5,Business and Professions Code:Any city or
O countywhichmquresapermittommtmd,alteglmpmve,demollah,orrepair TEMP.MLTFR OR IDLE MST.
P`'S t� any strecompdmtoltalsmance,alaorequirmtheappliranlfordeltpermlt to InWER DEVICES
u file a signed statement that he b licensed pursuant to the pmv6loa of the
Oy Contractors License Law(Chapter 9(mmmeacingwith Sodom 70W)ofDivi-
30�' dl.n3 ofthe Business and Profeselmu Code)orthat he is exempt therefromand SWIMMING POOL ELECTRIC VALUATION
the baste for the alleged exemption. Any violation of Section 7031.5 by any
<5
applicant Cora permitsubjects the applicant toadvilpenalty ofnor=to than 0[TCLETSSWI7CHE°rEXTU14ES �OO�D-,moo
flue hundred1,aswner of the W). NEW RESIDENTIAL ELECTR SQ.FT. STOWES T1T$CONSTRUCUON
I,as owner of the a work,
a or he employee with wages a thele dole
compensation,will dash.work,andtheet uccom ode:Tbn coats ded orcenseM for
dale(Sec appy Iftto an ow end f property
rops ty Code:The or impdots License Law
does whoclot apply ssuchtoanownerofthrougywhobuilds nempoyeas,povidedthmond OCC.GROUP RES.UNITS
CC whodvementsa notinte intended
hieownemp,hcxac arotidedthal uch gor
r
improvements sold Intended earofcdf.rsai the ner-b deer ilI haw TOTAL:
improvement within oneyeamfcompldiorythe owner-bullderwlll have
04jiurden of provingthat he did not build or improve for purpose ofnb.). QTY, PLUMBING PERMIT FEE F'LOODZONE APN
U L as owner of the property,am exclusively contracting with licensed
contactors to mostrud the project(Sec.7094 Business and Professions Code: PERMIT ISSUANCE
The Contractor's Limme Law does not apply to an owner of property who ALTER-DRAM kVENT-WATER(EAI
builds or Improves thereon,and who contracts for such pTjeds with a
agp¢.dor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec B k P C for this rem
an
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORK MAN COMPENSATION DECLARATION❑ FIXTURES.PER TRAP SC1iQOL TAX Y_ N—
I hereby affirm that I have e of consent m aeBre
-inm ,or RECEIPT X
certl(Iate ofWorkere C.mpeaatlonfmumnurance oraartlfled ropy thereof(Sec. GAS F.A.SYGTEM-I INCAOUTLETS
3X00,Gb CJ B PARK FEE Y N
.Bmry CepnvtlfiN I T t -
IN
PT It
CoGAS -OVFdR4(PA) BUILDING DIVISION
ISION FEES
❑Certitled ropy V filedwith the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECC FEE
CERTIFICATE OF O(EMPTION FROM WORKERS` CREASETRAP PAID
COMPENSATION INSURANCE SEVERSANITARYSTORM EA 700Ff Date Re i t#
Ohio section need nu be completed if the pemmt V(Drone hundred dollars
(ilm)orless.) WATER IiEATEi W/VEJT/7I.[CTR ENERGY FEE Y N
I artlfy that In the performance ofthe work for which this pehe
rmit le timed, —
1 shall not employ any person In any manner m as to become subject to tWATER SYSIEM/TREATING
Worken'CompeaationUwsof C.hf.aia.Date PAID
z Z Applicant Date Recei t#
'Z O NOTICETOAPPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT,
Hshould become sub)ed to the WorkerCompensation provisions ofthe Labor TOTAL:
fA Code,you mo at forthwith comply with such prottl.a orchis permit shall be
> deemed revoked. BUILDING FEE
LU0. C CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirmthat there N a mnstmdion lending agency for the perform- ELECTRIC FEE
O
7 O ance ofthe workf.rwhichthis permit is Issued(Sm.3097,Civ.C.) TOTAL. PLUMBING FEE
lender!Name
LL Lender's Addres QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 Aifyth.t l have read thieappllevionendatatethattheaboveinf.modion
IL bcorred.I.gree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
>. N relating to building mmutrodion,and hereby authorize representatives ofthb
H Z city to enter upon the abovcmentloned property,for Inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,Indemnify an d keep harmleas the City of Cupertino Date Receipt#
against liabilities,pdgnmrb,costs and expenses which may In any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
aga sat said City In coomqu ance of the gram Ing of this permit.
AIR HANDLING UNIT(OVER 1p,000CFM) CONSTRUCTION TAX
Signature of Appilaud/Contractor Wte D(HALsr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies at or future build Ing occupant store or hand le havardous HEATING UNIT(TO 100,000 BTU) Date RCCeI Icy
material as defined by the Cupertino Municipal Code,Chapter 9.1,,and the -
Ilealthand Safety Code,Se Ion 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea s2N.
Will the applicant 57M re building occupant use equ 1pmoat or d evices VENTILATION PAN(SINGLE RESID) — ISSUANCE DATE
which emit hazardous air contaminants as dell ned by the Bay Area Air
y1Co..Illy Management District? BOILER COMP(3FR'OR 100,IX0 BTW Q 1�pt{rh�(♦p
I Yea 4ro air C:SB U
haifornia Health
us Code,le tons,2m05,2553aChapter.1 of BOILER-COMP(OVER 100,000070) -JAN
the California Health ASafay Code,Section 25505,ve,a tarsal,,that it
�...�� uMentandytohat rnthe lythebuilding does nm cv rreuir haveaichmostle Lsmy NEW RESIDENTIALMEIN. $Q.FT.
prior blllty tonolify the occupant o(the qulrcmente which must be met
priorto m of a Ific�te"o.
Owner or auth°riud agent Date IB
TOTAL: ISSUED
OFFICE COPY