21925 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -PERMITNO.
Building Address: f1 n f'GI
pr l iEU G V9
w ers ams: Phone
CITY OF CUPERTINO-BUILDING DIVISION ( `' _G
cono- 'seams: . - u.xo: APPLICATION /PERMIT l T
A sectBUILDINGEL TRICAGPLUMBING-MECHANICAL CATEGORY CONTROLq�
lI L c.No:
"'QTY ECEC`TRIC PGRINIT "$E$ BUILDING PERMIT INFO
ddrese: - PERMITISSUANCE c -
LICENSEDC TRACTOR'S DECLARATION
I hereby
daffirm that laml e3.fthunder provtsloosof Chapter 9(mmmeno- APPLIANCESRES[DENTIAI. JOB DESC ON
Ingwai'lKV11formof Divi a d. ofthe9uslneesandl'rofesslonsCode,and my
license Is i ll force and effect. PA
License CW Lic.p
ale Contractor
���s�rra
ARCHITECT'S DECLARATION 20
qqqq p CO Land my phos shall be used as public remrds. O SQ,FT.
FLOOR AREA $/SQ.IT.
H�6Licensed esebrul SIGN CAL ( l L/yd���l///p 7(/ryi
tkg' " OWNER-BUILDER DECLARATION SPA
7p, Iherebyarmthat I am exempt from the Contractor's Licen
fRseLawforthe
oo
following reason.(Section 7031.5,Business and Professions Code:Any city or
O Z f. TEMP.METER OR POLE INST. ( C O
P� fountyng easy e.(SecipermBtomnstessand Pbnprove, e=lCode;hormpAnycity or
11 nystructure prior to its isaaance,alsorequireathe applicantforsuch permit to POWER DEVICES r,tG�i
C c. file a signed statement that he 1s Ilcensed pursuant to the provisions of the `(p
3u, Contractors License Lew(Chap[er9(mmmencing with Section 7000)of Divi- VALUATION
In SWIMMING POOL ELECTRIC
�Oa sion3 ofibellueinesand ProfessimuCade)orthat he is exempt therefromand /
•--11 the basis for the alleged exemption. Any violation of Section 70313 by anyD spl, 1
applicant for a permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHESFIXTURES S /
five 1,as o nerdelof the pr. NEW RESIDENTIAL ELECTR SQ.FT, STOI ES TYPE CONSTRUCTION
..at ❑I,as owner of the property,or my employees with wages r their sole
c mp:.s.a7 ,wllldoNand Prandine work� stode:Th not Intended o icanoffered Law
p sale(Sec.apply
Business and f property Code:The Contractors License Law
Q whododoes lapply torn owner ofpropertyhisonemorlmprowas ovidedrmn,and
uch
�3^ whodoeseuchwork himself orthrougM1 hisownemploy¢es,provided that such OCC.GROUP RES DNTTS
improvements arc not Intended oroffered forsale.If,however,thebuilding or TOTAL: L
Impmermentissoldwithln mayearofcompletion,the owner-budderwill havem
11e4urden of proving that W did net build or improve for purpose ofsakJ. Q'lYt "PLUMBING PERMIT i, "' FEE'" FIAOD TDNE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professlvns Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)'
Wilds or improves thereon,and who contracts for such pie)ecb with a c.
<q inver(s)licensed pursuant to the Contractors License Law. 'FEE.SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date REC TFT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that 1 have a certificate of consent to self4ruure,ora RECEIPT M
380Q Lab CJ
rerti,IabC.Workers Compensatlanlnsuranre oracerti(kd mpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS � '� PARKFEE Y N -
1'ollry# CAS EA.SYSTEM-OVER 4(FA) RECEIPT#
Com any - BUILDING DIVISION FEES
[Certified copy la herebyfurnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city Inspection division. �1 t'
CERTIFICATEMPE SATION N FROM WORKERS' '
GREASE TRAP PAID ,6� '
COMPENSATION INSURANCE SOVER-SAMTARYSTORM EA2WFT. Date Recel t#
RM1lusection need not W completed If the permit ic(Drone hundred dollars . -
($100)or less.)
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
certify rtify that In the performance of the work for which this permit is issued, �aO
I shall not employ any person In any manner to as to become subject to the b
WorkersCompensation Laws of California.Date WATER SYSTEM/TREATING PAID .�-►y-�I
0 Z Applicant NEW RESIDENTIAL PLMB. 5Q.FI'. Date Recei t#
Z O NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,you
f W should become svb)Da to the Workers'Compersatlon pravbkmvii Labor - TOTAL: /
Code you must forthwith comply with such pmWloos arthia permit shall be
LU j ammaa revoked. BUILDING •E
CONSTRUCTION LENDING AGENCY SEISMIC FEE , (�
a a.ftb warkftrvvMc tIsaermftI tion lasued(Sec.3genryforth¢perform- ELECTRIC FEE
Z anceer'sNwork(orwhichthis permitis issued(Sec.3097,CIv.CJ TOTAL s
U O Lenaera Name PLUMBING FEE
IL F tenderaAddrese QTY.'` MEG$ANICAL'PfiRMIT E.' MECHANICAL FEE t
OW I certllythatl have read thisapplicitlonand statethatthe above information rr'�
C iscorrect.I agree to complywith all city and county ordinances andstate laws PERMTTIS5UANCE l GL FEESFAID:
} relating to building construction,and hereby authorize representativee of this
N -
)— U) city to enter upon the above-mentioned property for lnspectionpurposn. C ALTERORADDTOMECH. - s ,
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,mrtsand expenseswhich may inanywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga Inst said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous HEATING UNIT Q0100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the -
IicalthandSafetyCod ction 25532(a)7 HEATING UNIT(OVER IDQ000 BTU) TOTAL:
❑ Yes No
Willthe applicant re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamedous air contaminants m defined by the Bay Area Air
Quality Managementis ct2 BOILER-COMP UFR'OR 100,W0 BTU)
[Th
Yes No
Ihaveread/ eh ous materials requirements under Chapter 6.95 of BOILER-COMP(OVQ2100,000 BTU)
the Califor Ieaith y ode,Sections 25505,25533 and 25534.I
is atifthebu'di doesnotmrmntlyhaveatenarat,thatitismy NEW RESIDENTIAL MECH. SQ.FT.
respon i ylonotifyt mant oftherequirommawhich ett, �Il l4 N 1
prior uanceea a tocm I
nor or authorised Dat ISSUED BY:_ _ - Z
TOTAL:"
OFFICE COPY