21586 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification (�,^�s[` PERMITN///O.
Building Address: �sYTT '/1 C
21 5
wners ane: one: A
CITY OF CUPERTINO-BUILDING DIVISION
Cont ctcr.Name: APPLICATION I PERMIT
J-0 BMLDINGELECTRICALPLUMMI C-MECHANICAL CATEGORY CONTROL#
Arc Ilett gine¢,... Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - PERhIITISSUANCE �tY ❑ ❑ ❑
ery iron that
ED CONTRACTOR'S DECLARATION u
Ihereacti..7000).famaErm3 fthe er Buinessaonsof Cssions9de,and e- APPLIANCESRESIOENTIAL - JOB DESCRIPTION
IEcanse in 117D00)o(d dieon3 ofthe Busiureeand Pm(esslone Code,and my
license Isla toll dLie.N - PANELS
Date Clam
Date GQ,(O/1/QyUP TO 2EeAMPq -
ARCHITECHITECTSDECLARATION 201-1000 AMPS
q�q�ur ne ZpC Iunderstand my plana shall he used as public records, OVER10DOAMPS - ;SQ.FT.FLOOR AREA 5/SQ.IT.
Ltcennd Professional _ SIGNS ELECTRICAL I I" �:v iR_• '\ �: E. ® IN
,
<< OWNER-BUILDER DECLARATION SPFOIALCIRCUIT/MISC IF -, \ f �'
Iherebyaftim thatI am exempt from the Contraciorb License Law for the a �, "'�
2o following reason.(Section 7011.5,Business and Professions Code:Any city or /?
02t.� TEMP.METER OR POLE INST. 012 �yJ
� county which regWreaapermi[romnstmR,alter improve,demolbh,orrcpalr
P a anystmcture,prbrmits issuance,alsomquirestheappBrantfwsuch permitto POWER DEVICES ,• DATE
file a signed statement that he le,licensed pursuant to the pmvlslon+of the
O o, Contractor'.License Law(Chapter 9(commencing with Section 7000)of Div" '-
�0 SWIMMING POOL ELECTRIC Bion 3 ofthe Business and PrdeeduraCede)or that he Is exempt therefrom and � ��Nr _
Q the basis for the alleged exemption.Any violation of Section 70115 by any OUTLETS-SWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not mare than
five hundred dollars%5D0). NEW RESIDENTIAL ELIGTR SQFC. STORIES TYPECONSTRUCTION
F1 I,as owner of the properly,or my employees with wages as their sole
qcompensation,wBldothe work,andthe stm=m le not intended or offered for sale(Sec 7044,Business and Professl..Code:The Coptractori License Law
rig does not apply to an owner ofproperty who Wilds or improves,thereon,and' OCC.GROUP RES.UNITS
whodcessuchworkhimaeBorthrough Nerwnemployeea,pravidedthatsuch
improvements are not intended oroffemd fm ole.l(however,thebuilding or TOTAL:
improvement lssold withinoneyearofcompl&iorytheawner-bullderwlll have
tllkurden of proving that he did not Wild or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,sin exclusively contracting with licensed PQtM).1.155[IANCE
contractors to construct the project(Sec.7044,Business and Professions Code: ,
The Contractor'.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such plojeRa with a FEE SUMMARY
O�7Btt ctw(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reasonOUTSIDEFTES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RFOEB'C If
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SC{(pLTAX Y N
QY�,ereby affirm that I have a certiBcete of consent to self-Insure,or RECEB'C X
certificate of Worksrn'Comperwtlon Laurance me certified ropy thereof(Sec.
3800,lab CJ
GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polity# z41"/,q7dV3 GAS E .SYSTEM-OVER4(EA) RECEIPT
Compa DINGDIVISION
FEES
5C
copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECICFEE
[agartBled copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20UFT Date ReC'eI t#
(Thlssectun need nR be completed if the permit)sfw one hundred dollars
(810(fimlessJ WATER HEATER W/VENC/E[FOTR ENERGY FEE Y_ N_
I notify that In the performance of the work torwhlch this permit is blued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws,o(Call(ornla.
Data PAID
OZ Applicant NEWRESIDENTIALPLMB. SAFE. Date Recei t#
Z O NOTICEco e..bjcttothe mi making this
nsatio Certificate o(Exemption,eLyou
f" should become aubpR to the Workeri Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisiwu orthb permit shall be—
W j deemed revoked. BUILDING PEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE AM
CL 0 Ihereby af(Irmthat there lsaconstruction lending agency for the perform, TOTAL: ELECTRIC FEE
M
Z anceofthe workforwhichthis permit is Issued(Sec.3097,CIv.C.)
V O' r Lender's Name PLUMBING FEE
F Lender's Address - QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W omactfythatecto c mply sth all city and county
hatthe ordinances above information
fl Is correR.]agreeto comply with all city and county ordlnancesand date laws PERMITISSUANCE FEES PAID:
�- relating to building construction,and hereby authotlpreeentativesofthis
H N u re
city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z gree to save,indemnify an d keep Far ass the Cityof Cupertino Date Receipt#
V agal t abillBes dgments,mete and exp¢ hlch nay In anywayacarue AIRHANDLING UNIT(TO10,000CFM)
SUBTOTAL:
ago t old Ci nuns ¢ gra go(this permit. SIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SI store of ApplicDate EXHAUST HOOD(W/D[KT) CONSTRUCTION TAX PAID:
HAZARDOUS
MATERIALS DISCLOSURE
Will theappllcant orfuturebuilding occupant storcorhandle hazardous HEATING UNIT(TO 100,000 RTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilcalthand SafetyCade SeRlun 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Iia
Yes o
Will theappllcant or future building occupant use equipment or devices VFXULATION PAN(SINGLE RESIDE ISST,[ ATE
which emit hazardous air contaminants as defined by the Bay Area Air -
IltyManagement Dis - BOILER-COMP TLB'OR 100,"BTU) y
rwF
as
ihaeread the hnaar ausonaterlalsmquimm ntsunderChapter6.95of BOILER-COMP(OVER 100,000 BN) Co
the California Health&Safety Code,Sections currently have a Land,that 1 'C F rIP V
rete Inde d tha�g does not currently have a tenant,n ut it le my NEW RESIDENTIAL MEC{. SQ.FT. CIt}?t�fi�fJQS^."li .
resp $Ility to oti(y theompant th uircmen vhich must be met '
prl L, ssuan o(aCe .tr ry.
Owner or authorized agent Data ISSI]ED BY���
TOTAL:
OFFICE COPY