21761 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
•
Building Pro'en Identification PEILWT NO.
BaBf ng Address:
s 21.7 61.`
wneaces: one:
(i;,-:cTC-UNG• (40072/-3/99 CITY OF CUPERTINO-BUILDING DIVISION
Cont m's ,Fay��a/a,� .No: kfs
APPLICATION /PERMIT
Lk.No: O J
LDING-ELECnUCALMUMBINGMECHAMCAL CATEGORY CONJ(�GOg •'.
Architect/Englnnr.
qrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:�IO �}/O �' /,V - S. T•a CIF PERMITISSUANCE `Ztfb
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(common, APPUANCESRESIDENTIAL )OB DESCRR'TION
Ingwith Section 70000of Division3ofthe Businessand ProfeselonsCode,and my
liana Is in Tuft form and ellen. PANELS C License ^�`1�
Data jC.nmacm, UP TO 200 AMPq
ARCHITECT'S DECLARATION 201-1000 AMPS
q�u aO ZZ I understand my plans.haft be used as public remrda. OVER 1000 AMPS Sq.FT.FLOOR AREA �-ISS/`ySQ.NFNT.
Licensed Profesuore SIGNS ELECTRICAL �2 61843
WNER-BUILDER DECLARATION
L�lxl.Z
d'4- OSPFCIpLCIliCU1T/34150' La,
z �a5 I hereby affirse Zt I am exempt from the Contractor's Meares Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
1 S96 M
9 TIMP.METER ORPOLE INST.
county which requires a permit to conftmtl,alter,Improve,dem elish,or repair
any structure prior to its Issuance,a bo requires the applicant for such permit to POWER DEVICES
0. file a signed statement that he b licensed pursuant to the provisions of the
3w Contractor's License Law(Chapter 9(commpncingwith Section 7000)ofDist.
�0 kon3ofthe Buslnnsamd Professions Code)orthatheisemmpttherefromand SWIMMING POOL ELECTRIC VALUATION /
O 5 the bean for the alleged exemption. Any t tolasion of natty o&7a3on by any OUTLETS-SWITCHES-FIXTURES S6/ ��t
app0andfor.permit$500. sthe applicanttoa civil penalty of nn marethin
$ five E,as
demodeltathepr. NEW RESIDENTIAL ELECR SQb7 STORIES TYPE CONSTRUCTION
`]Las owner of the property,or my employe with wages thele sale
t m(Sec.744,wBlaotbewort;Prodesthee ode:e Is Thn r IntendedCorseted or License
Law O
$�O sok(Sec.7046,Business and Profenlow Code:The Contractors Llame law
does not apply to an owner of property who builds or improves thereon,and c
f�Lt who does such work hlmselfor through his own employees,provided that such OCC.GROUP RPS.OMTS
Improvements are not Intended oroffered forsals.If,howemrthebulldingor TOTAL: (�
Improvement b sold within oneyearofcomplelon,the owner-budderwlll have
thAjZardes of proving the he did nm build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE, If TVDM APN
7,as owner of the property,am exclusively contracting wOh licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business end Profemoms Code:
The Contractors n License Law donot apply to an owner d property who PETER-DRAIN&VENT-WA -
Wilds or improves thereon, and who contracts for such pipjern with a - t EE SU MARY
cgR2T�noxa)Ikensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE. -�
U I am exempt under Sec. B 6 P C for this reason
DRAINS FLUOR ROOF,AREA,COND. SAMTA
Owner Date RECEIPT a
WOR"AN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a eartiflrate of consent to aelf4asurs,ora FIX.NRES RECEIPT N
mAtflceteofWorkea CompermationlmsunnaoracertBled copythereef LSec.
3800,lab C.) GAS EA.SYSTEM.I INCAOUTLETS PARK PER Y_ N_
RECEI7I N
policy Y GAS EA.SYSTEM-OVER 4(EA)
Company BUILDING DIVISION FGI[S
I ICertlflad copy is hereby famished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKPEE
LY—J CeniOed copy b filed with the city Inspection division.
I CERTIFICATE OF E%EMPTION FROM WORKERS CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-S10RM EA.20071'. Date Rewi 1# J 6 '
(Thissection need not becompleted If the permit b(prone hundred dollars
($1I wrtifyth WATER HEATER W/VENT/E.EGTR ENERGY FEE Y - N—
I
artily the o the person
anof y
m work so as to b this penult b blued,
1 shall not employ any peaon In any manner w u to became subject to the WATER SYSTEM/TREATING � L17/ C
Workers Compensation laws o(GII(omla.Data PAID��'� v.7{O NN��
ZIcam
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQpP. Date Recel t#1Z.A
Qshould become subject to the Workers'Compensation proWbm ofthe Labor
p1 Code,ym=stfanhwlthcomply Mthsuchpm islomorthbper tshallbe B NG /
W 5 deemed revoked. r
IL c CONSTRUCTION LENDING AGINCY SEISMIC FEE b
Z Ihereby a(firen that there b amvtruction lending agency(orthe perform TOTAL: �'7O ELECTRIC FEE
D O arcs of the work for which this permit b Issued(Sec,3097,Civ.C.)
0 I,enders Name PLUMBING FEE a O
�' Leelars Address QTY. MECHANICAL PERMIT ' FEE CILS-,70-
0
p
LL MECHANICAL FEE
OW Icenlfythatl have readthlaeppllcatlonand atatethatthe aboveln(ormatiw
IL borrect.I agraelu comply withaR city and county ordinance and nate lawn PERMIT ISSUANCE. FEESP
} relating to building construction,and herobyauthoroarepeamumivnafthis
H Z city to enter upon the above�mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Da R el t#
V
against liabilities,pdgments,mks and expenses which may In any way some AIR HANDLING UNIT(TO 10,ODO CFM) OTAL• t6-5
against said City In="us=of the granting of this permit.
AIR HANDLING UNIT(OVER I0,0DOCFM) CONSST••R AX
on
Signature of AppOcant/Ctractor Data EXHAUST HOOD(W/DUCT) CO�� ION X PAID:
HAZAR DOES MATERIALS DISCLOSU RE x� 0.
Will the appBant or future building occupant store or handle huardous HEATING UNIT(TO 100,000 BM Date ej t# I ✓ a
material as dell red by the Cupertino Municipal Code,Chapter 9.1 7,and the
Ilealth and Safety Code Section 25S32(a)? HEATING UNIT(OVER 100,000 BTU) TO -
Yn N No
Will theappllcantorfuture building occupantusesgWperent ordevlas VENTILATION PAN(SINGLE MSID) ISSUANCE DATE
which areft haezrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,0(]BTU) _
❑Yes ❑No
I have read the harxN us materials requirements under Chapter6.95 of BOILER-COMP(OVER100,000 BTU)
California Health k SafetyCode,Sections 2550.5,25533 and 25534.I
undmtand that ifthebullding don notmmntly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which moat be met Na..
prior m issuanw of a Certificate of 0aupancy. ^^
0.vner or authoaud agent Data p ISSUED BY: k
TOTAL: 1. • O
OFFICE COPY ��