21508 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification PERMIT NO.
Build ing Address: 21508
1 5 O n
� G I lel(
wners ante: one:
37
CITY OF CUPERTINO-BUILDING DIVISION
Cont T�iiine: LIe.Nn: APPLICATION /PERMIT
G vBU(LDINGELECTRICALPLUMBINGMECL LAICAL CATEGORY
Lc. o: SCO V Bb M/T
O(,o
rc itect/Engineer:
a- 714 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddressPMMTISSUANCE .�2,Q0 Imo! �/II ❑ ❑
LICENSED CONTRACTOR'S DECLARATION r1 VS'f
I hereby a((Irrn that l am licensed under provisions of Chapter 9(comment, APPQANCFSRESIDENTIAL , JOB DESCRBs]TON
ingwith 1 1fu n7(XD)of defDivision 3otthe Buelneuand Pro(essioneCode,and my ` STT
license is in luRf and effect. PANELS
License Cla Liep
Date mdrador_ .�/-•mss'
ARCHITECTS DECLARATION 201'1000 AMTS
Po?ec O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/9Q FT.
E Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION 'Y
t`n Td SPECIALCRiCU1T/MISC
P t., ahatlamexempt(ro ctorb Lkonse Lawforthe
OPHpp'Lv�i�rO'pq�:7�yJ
following reason.(Section 7 Business andPmIeuloee Code:Anydryor
ontyrcquimsapett.rotM.1tpmebh,orrcpar
TEMP.MF7QOR
[OLE INS(
.
anyatmcture te lawance,aoreguimsthealntforsh t POWER DEVICES a signed statement that has b icansed pursuant miles revisixi of the
ConhLiensLa pter9(ommencing with Section 700))
Divi. gWIMAqNG IDOL ELECTRIC
sonooftheBusinessandPmfeulosCode)arthat helaexempttheeformand
ma�'�y�..s a a�,�o,�sL�
VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.5 by any �
OUTLETS-SWITCHESSFIXTURES G.•Vs.,,�+
O
applicant fora permit sabirdatheappllosnttoa civil penaltyof not marethan —5 1
five,hundred dollars(S500). NEW RIiDENTIAL ELECTR SQ.IT. - 5"TORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,win do the work and the stme re is not intended or offered for
O .le(Sec 7614,Buslness and Professions Code:The Contractors License iaw
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROU(' RIS.UNITS
who does such work himself orthreaugh his own employees,provided that such
Improvements are not intended oroffered(orsale.If,however,thebullding or TOTAL: _
Improvereentissold within oneyeamfcompldlomtheowner-builderwlll have ,
tr rdce of proving that he did not build or Improve for purpose ofule.). QTY. PLUMBING PERMIT FE
_j FLOOD 7�NE APN
LJ L as owner of the property,am exclusively contracting with licenandi
outCode: pp-((MIT ISSUANCE
The Contractor's
to construct Liventhe project(Sec.apply
Business and of property Code:
The Contractor's es thea law does net apply to an owner of property who ALTER-DRAIN k VENT• A
Wilda or improves thereon,and who contracts for such p.oj•cte with a FEE SUMMARY
ro151ar(eexemptlicensed
under Sec.ant
the Contractor's License Law. BACK FLOW PROTECT.DEVIC -
u I am exempt under Sec. B h P C for this mason
OUTSIDE FEB-
Owner DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y N_
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRV' SCHOOL TAX Y_ N_
❑I hereby affirmorkem that I have o certificate of convent to epythemo ora RECEIPT N
3800,L�difiateo(Worken'Compensadon Insuranceoraremfkd mpythereofpec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380q Fab C3
Policy Y RECEGAS EA.SYSTEM. DING DT p
OVER 6(FA)
AC.,,o,,,�����m p(;�aaart BUILDING DI VISION FEES
fertllled copy b horebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHE EE
f edBled ropybflled with the city Inspection division. �I
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID s�
A COMPENSATION INSURANCE SEWER-SANTTARYSTORM E.A.2DIFT at 1#
(This section need not W completed If the permit b for one hundred dollars
(B1I0)orlessJ WATER HEATER W/VENT/ELECTR ENER
I mnotrtify that o the performance of lheworkmanner(o as to b this permit is owed,
I shall not employ any person In any manner so v to become subject to the WATER SYSTEM/TREATING
Workem'Compenaa(ion laws o(GIIlomla. Data PAID
O Z Applicant
Z Q NOTICE TOAPPLICANT:If,after making this CertBlcateofExemptlon,you NEW RESIDENTIAL PLMB. SQ.Ff. Date Reeei t#
should become subject to the Workers'Campersatlon providomoflhei.abor TOTAL:
CC W Code,you=at fort hwith comply with such provisions or this permit shall be
jdeemed revoked. B
W S CONSTRUCTION LENDING AGENCY SEISMIC PEE
Z
I hereby affirm that there is a construction lending agency for the perform, ELECTRIC FEE
anc
e of the work which this permit b Wried(Sec.3097,Civ.C.) TOTAL:
U O bender's Name PLUMBING FEE
LL ~ LendcrsAddress Ory. MECHANICAL PERMIT FEE MECHANICAL FE
OW Icertilythat l have read thin application and ratethat theaboveieformxtton
1 is co—.I agree to comply vith.11 dtyand county ordinances and rate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives ofthic
Z city toenter upon the ahm"onontloned property for impaction purposes. ALTFRORADDTOMECIi. Date R eei t#
V _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against ilabillt judgments,costs and ex s which may In any wayaccrue AIR HANDLING(INH'(TO 10,000 CFM) SUB OTAG
agsln said nems eo a this permit.
AIR HANDLING UNIT(0VERI0,0a0CFM) CONSTRUCTIONT X
Sig core of pucant/C actor to IXHAUSTIIOOD(W/OUCH' CONSTRUCTIONT XPAID:
HA OUS MA TERIALSDISCLOSURE
WllltheappBcant future building occupant store or handle hazardous HEATING UN T(TO 100,00011M Date R ei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cod�lon 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TO
❑ Yes No
Wllltheapplicant o future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which coat hazardous air contaminants as defined by the Bay Area Air
1
Quality ManagementD tdct7 BO LER COMP OF OR 100,000 BTU
RAM
1AYesNo
averead teeth& fty Codelalarequi 25505, 5533 aChapter. 1 of BOILER-COMP(OVQ21fA,000 BTU)
the Gltandt Health he building
Code,Sections25505,ve a Land,that
r7'
understand team notify
the occupant not the
menta which
that it is rout NEW RESIDENTIAL MECFi. SQ.FT. it F
rcspo 'il yto ndily the occupant of the rcquircmenta which must be met
to ono ance lost of Otecupan 4'
n r r uthorize gent pate / ,��lyY -
TOTAL: ISSUED BY:_
OFFICE COPY