21658 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Adcirx ya. 21658
168
n a ante: ane:
SUBMITTAL
.✓_/°�/ 7 /1-y,///_ s/CITY OF CUPERTINO-BUILDING DIVISION I �j
Cmanteme.Name: _ Ue.No: APPLICATION /PERMIT `�� `o l
✓N4/I-✓C/-' K C!f/d `'/�1� BUILDINGELECTRICALPLUMBING- CATFLORY C NTROLN
MFATIANICAL
Architect/Engineer. Lic.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
ly Hurebyafftmn chat am licensed under provisions of Chapter 9(commena APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingres Sctlion7000)o1fAv1fact. fthe Bueinessand Pro(esslomCoae,and my S�;zy
Ilimm lain fullJprce end e.N PANELS
Date Cljss UTI LION c �j ) �y
1
Can dor —UP TO 200 AM
ARCHITECTS DEC AJA p1CHITECTS DEC AN X11ER10AM
0'L [understand my plans shaBbe used mpublic records OVER 100000 AMPS SQ.IT.FLOOR ARTA 8/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
1'n 3SPECIALCIRCUIT/MISC
zF, Ihercbyaf0rm tlutlam exemp[fromthe Contractor's License Law for the
County w reason.(Section 703L5,Busmen and Pro(eseve, Code:Any city lr
0 f"u9 county which rcqulresa permittocowtrutt,altar,improve,demolish,orrepalr TEMP.METE20RPOLE[NST.
'�Sd anystrocture pdortoits Issuance,also requlrealheapplkant forsuch permit m POWER DEVICES
O file a signed statement that he is;licensed pursuant to the provisions of the
14
�OSContractor's License Law(Chapter 9(commencing with Section 7000)of Div1-
Mon 3 of the Business and Profeaslona Code)orthat he sa exempt therefrom and SWIMMING 100E ELECTRICVALUATION
the basis for the alleged exemption. My vlolatlon of Section 7MIS by any
O appficantforapermitsubjets theappllcanttoa civil penalty of not more l ban OUTLETSSWITCIiFSEXfIRtES
$ five 1,as o nerdolof the pro NEW RESID=AL ELECTR SQ,frf, RIES 'TYPE CONSTRIIC7'ION
�n ❑I,as owner of the property,or my employees with wages r their sole
competc.70 n,Bouirs he a twork andthe structure ts not Intended or offend for
M sale(Sec.7096,Businnsand Pro(e.loro Coda The Conlractofs Llceme Law
does not apply to an ownerofpropertywhobuildsorimprovesIhamon,and OC GRO RFS.LIMB
CC.• whodoessuchwork Mmselforthrough hisown employees,provided that such
Improvements are not intended oroffered forests.If,however,the building or TOTAL:
improvement 6sold Mthinoneyearofcomp:&Iorytheowner-buRderwRlhave
the*rden of proving that he did net build or Improve for purpose ofsale.). QTY, PLUMBINC.PERMIT FEE DIANE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ssl
to consimet the pmject(Sec.7044,Business and Profeoru Code:
The Contractor's Llcen.Lew dues rare apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereoe,and who contracts for such ptojecte with a
eqnLipetar(s)ureneed pursuant to the Contractor's Llan.Law. gpIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reawn
• FEES
Owner DRAINS FLOOR ROO$AREA,GOND. SANITARY Y TOUTSID#
Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FDnURFS PER TRAP SCHOOL TAX Y N
ae
❑I hereby afflorn orkemthat 1 have o lmumne of consent to pytheure,ora RECELPTN
3800,Lab of Worken'Comperualionlnvurance ora certified ropy thereof(Sec. GAS EA.SYSTEM-I INC.4 OUTLETS PARKFEE Y N
3800,Lab C.)
Policy N - RECEPT N
m any - - GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
Red copy 6I.hercbyth the city GRFASE/INDUSM WASTE INTERCEPTOR PLANCHECK PEE
cenmea copy b reed with the dry wpmmn arolsmn.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM EA.200FT. Date ReS2! tit
(TFisaesis) need not be completedif the permit l9 forone hundred dollars
(810cnilyt.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Illnot thato the personanrenymofthe workto as tobwhich thispermitisLtothe —
I dull not employ any person In any manner n n to become subject to the
Workers Compensation Laws of California. ATER SYSTEM/TREATING
la.Date PAID
O Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z Q NOTICE TO APPLICANT:If,after making this Cenlfleste of Exemption,you
should become subject to the Workers'Compensation providmu of Labor TOTAL:
~ N Cod,you at forthwith comply with such prevail..or thin perentshall be W -BUILDING "> aeamea revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE `
tl TI
I ht.by affirm that them ts a construction leading agency for the perform- ELECTRIC FEE
:3Z anceofthe work(orwhlch this permit is Issued(Sec 3097,Civ.C.) TOTAL:
OO Langan.Name PLUMBING FEE
LL — Lander'.Addreas QTY. MECHANICAL PERMIT FEE , MECHANICAL FEE
O W I cenlfylhat l have readthb application and statethattheabovelnformation
bcormR.I agree to comply with all cltyand countymeltnaneesana statelaws PERMIT ISSUANCE FEES PAID:
} L relating to building construction,and herebyauthorbe representative;ofthb
I" N city to enter upon the above-menllondproperty for inspectionpurposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmlen the City of Cupertino Date Recei tit
V
effacer abllltles,jodgment;,mate end expenses which may In anywayacceue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga is. City in conseque of the gra eg of this permit
AIR HANDLING UNIT(OVER IQOOOCFM) CONSTRUCTION TAX
rcofA are Date EXHAUST HOOD(W/D1X:3)' CONSTRUCTION TAX PAID:
Mico RDOUS MATERIALS O ISCLOSURE
WIIl the applicant or(umrcbullding occttpant store or handle hazardous HEATING UMT(T0100,000 BTU) ' Date Receipt#
material a;defined by the Cupertino Municipal Code,Chapter 9.1 I,and the -
Health and Safety Cades.S�ection 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
r
❑Yes L_I No
Will thezpplieanl orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) INCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air ''®®
. Quality Management District? BOILER-COMP(3HP OR 100,000 BTU)
4 Yea No
have,ca
nuterizis requlrcmeent under Chapter 6.95 of BOILER-COMP(OVER 100,000 BIU) 1 i
the California Health&Safety Code,Sections 25505,75533 and 25534.1 .'AM- O A
understand that ifthebuildleg does not currently have a tenant,that it a,my NEW RESIDENTIAL MECH SQAT.
responsibility to nosily the occupant of the requirements which at be mat MLN
P0)
.n
prior to Issuance of a CenlficammOccupancy. J.�,
Owner or authorized agent Data ISSUED BY'�[/B
TOTAL:
OFFICE COPY