21454 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add rens: 21454
60(e`i Shad rove hove C u- iLetino CA 06oi
Hers time: CC 1one;
S�eVe �aLurll►e!5 X57-95-f 0 CITY OF CUPERTINO-BUILDING DIVISION A
LI,.NaAPPLICATION I PERMIT � D `� Vcon er m
bnC BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ N El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby,affirm that l am licensed under provisions of Chapter9 immature APPEANCESRESIDENTIAL IOB DFSCRIPTION
ingwith Section 7000).f DWIM..3ofthe Businessand ProfessionsCde,and my
license leln full f.rx andt.It
Date PANELS
Class It.Y
Date Contnci.r
ARCHITECTS DECLARATION 20140DOA.MIS
M7 I understand mypbrushalbe used as publleremNs. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
I� Licensed Profession) 9GN5 ELECTRICAL
I OWNER-BUILDER DECLARATION SPFf1ALCIiCUIT/M15C
H � Ihercbya0lrmthat lam exempt from the Contract is Llcenselawforthe
9— following reason.(Section 7011.5,Boniness and Professions Code:Any dryer
O G t- TEMP.METIR OR POLE INST.
Fg county rrquiresa permit tocontruq alter,bnprove,demolish,orrepair
q �Jp.�.a any structure prior to its Issuance,also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
�., Conlrator'.License Law(Chapter 9(mmmencingwithScdor7000)ofDlvi-
30�^ sion3oflhe Businnsand ProfeuiorsCde)orlhat heb euro therefromand NC POOL ELECTRIC VALUATION
the basis for the alleged exemption. My violation of Se tion 70315 by any
F
<�
applicant fora permit subjects the applicant to a civil penalty of not more than OUTLEISSWITCHE_SFIXTURES
y five hundred dolma(R500). NEW RESIDEN77AL ELECTR
E]1,as owner of the property,or my employees with wages a their sole SQ'FT.
STORIES ITPE CONSTRUCTION
compensation,will clothe work and thestrucium Is not intended or.ffemd for
p sale(Sec.7044,Business and Professions Code:The Contractors License law
does not apply to an no,a property who Wilds or improves thereon,and OCC.GROUT' RES.UNITS
whoduessuchworkMm lorthrough hisownemployeea,provided that such
Improvements are not intendd oroffered fornale.If,however,the W ildingor AL;
Improvement issold withinoneycarofcomplmiogtheowner-bufldcrwill have
aeno(proving that he did no[build orimprove for purpose ofsak.). QTY, PLUMBAGPERMFEE FLOODZONE APN
owner of the property,am exclusively contracting with limned PERMIT ISSUANCE
oteadore to construct the project(Sec.7044,Business and Profeeslon Code:
Contrator'a License Law does net apply to soowner a property,who AL -DRAIN
Wilds or improes vthereon, and who contracts for such pPK�with a -
Ct[atoKs)Bcenedpursuanttothe Cmtradorl Lku Law. Wim- C FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
s SANITARY Y N_
• Owner Date DRAT FLOG F, ND.
RECEIPT N
WORKMAN COMPCNSATION DECWRAiION �.�� SaBOOL TAX Y_ N
mni❑I hereby affirm that I have a lrt.ate of consent to pytheure,ora RFC=I-
3800,
Lab of Workers'Compertutlonlnuranmora certifkd mpythereof(Sec.
3800,lab C.) GAS Et. -1 .40 EIS PARK F'FF Y N
Poi' p —
CNCm any G STEM-OVER (FA DING 'T X
crtifird copy is hereby furnished. BUILDING DIVISION FEES
F-1 Certified copy is filed with the city inpeclon division. GRFASE/INDUSIRL WAS l ErrOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(ThissMi.n need Hat becompleled if the permit blut,rehundred dollars SLIVER-SANITARY-STORM EA.200FT. Date Remi t#
(5100)orlevJ WATERHFATEt W/VENT/ELECTR ENERGY FEE Y N
I ll not that o an person In a.(the wait so an to b this permit is Issued, —
I shall not employ any person In any manner ro tie to become objet to the WATER SYSTEM/TREATING O Workeas'Compensation Lawn o(Glifomla.Date PAID
N011C est
Z 2 NOTlCETO APPLIbecome,subject
tothe,cher making rn'Com er Certificate provisions
Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Reml
Cufi shoulddou most urthwit the ply with
Comp rovidnprovbis per it s Labor TO
WN deemed remuet(orthwlth comply with such providers or this permit shall be
> reamed revoked. BUIL TNG 'E
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Ihercby affirm that there Is a construction lending agency for the perform- rorni: ELECTRIC FEE
anti of the work for which this permit is Issued(Sec.3097,Civ.C.)
U O Lenders Name PLUMBINCFEE
1L Led,es Addm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certifythat l have read this application andaatethattheabovetnformdon
1 Isc.rmt.l agree to comply with all city and county ordinances and state lawn PEiMITISSUANCE FEESPAID:
} W reining to building construction,and hereby authorize representatives of this
I— Z dtyto enterupon the obove.mcntioned property for Inspection purposes. ALTERORADDTOMECH.
U _ (We)agree to ave,indemnify an d keep harmless the City of Cupertino Date Receipt#
again:Bab k;judgments,masa expenses which may lnanywayacaue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agaios ityi of
grantin :hispermit.
6-1 2M646e, 11-16-41D AIR HANDLING UNIT(OVER I0,OWCFM) CONSTRUCTION TAX
5' mrcof Applian, eotr Date Ek HAUSTHOODON/DUCT) CONSTRUCTION TAX PAID:
HA R qq SMATERIALS DISCLOSURE
Willtheappliant or fu (rc WBding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) D
material as defined by the Cupertino Municipal Code,Chapter 9.12.and the ate Remi t#
Section Health and Safety Code Sion 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yea r]No TOTAL:
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE uRESID) ISSUANCE DATE
which rout hazardous air contaminants as defined by the Bay Area Air
Quality Management D6trit7 BOILER-COMPOHPOR 100,000 BTU)
4 Yes MN.
Tuve read the hva outs materials requirements under Chapier6.95 of BOILER-COMP(OVER IW,000 BN)
the California Health&Safety Code,Sections 75505,25.533 and 2:534. I
u ndemta nd that if the Wilding does not mrrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which at be vert
prior to issuance of a Certificate of Occupancy. '
Owner or authedvN agent Date IbrA L: "SUEDB � �o
OFFICE COPY