21676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 1A.C.
Building Project Identification PERMITNO.
BuBding Address: 17 a�
(o D G I
� ��ne!qrfe ase: 676
one; aIAL DAIL
tNC 'Ell CITY OF CUPERTINO-BUILDING DIVISION 1 _ �C
• Comn
raor'cName: Lie.No: APPLICATION /PERMIT J
BUILDINGELECTRICA].PLUMBING-MECHANICAL CATEGORY CONTROL.II
Architect/Engineer. Llc,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I huh by Sectio irmthat lamsim3 dunder heBuMrovlandn fmzims9(mmmmc APPWANCESRESIDEMIAL JOB DESCRIPTION
Inense IS enlon forces ddiecn3 o(the ButlneeeandlrrofndonaCode,and my
license le ie full force and c.a PANELS
License Clam Llc.p 1VnYlrn\- i
Data Contractor UP TO 2DOAhTq
ARCHITECTS DECLARATION 201-1000 AMPS
rc0 OC I understand my pkm shallbe used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
t, Licensed Professional SICNSELECTRICAL ,
Q OWNER-BUILDER DECLARATION
l+n SPECIALCRCUIT/MISC
71.., ,wring.....nthatlam exempt fromthe Contractors License Law for the
following reason.(Seniors 7031.5,Bu.lnem and I'ro(emlone Code:Any city or
O TEMP.MEM OR POLE]NST.
Fp countywhich rcquinrea perMttomrutrun,aller,lmpmve,demolkh,or repair
W6
m a nystmnumpriortolUL ance,aborequirestheappUantforsuchpam tto POWER DEVICES
W V file a signed statement that he is licensed pursuant to the provlaloof the
Ow Contactor'.License Law(Chapter 9(commencing wilhSen1on7000)otDivi-
Og' alon 3 ofthe Business and Profemloea Code)orthat hale excmpttherefromand SWL4MING TOOL ELECTRIC VALUATION
the bass.for the alleged exemption. Any violation of Section 7MIS by any
< OUTLE7SSWITCHESFIXTIIRES
p untforapears(eubjecb the civil penalty of more thin --
o
u a.owner
U500). NEW RESIDENTIAL ELECTR SQFr, STORIES TYPE CONSTRUCTION
e ,as owner of the property,or my employees with wages as Ihelr sok
Cyt¢ cation,will d o the work and the structure k not Intended or offered for
5a O sale(Sec.7044,Business and Professions Code:The Contractee Lice•..Law
VsF does nut apply to an owner of property who builds or Improves thereon,and OCC.CROUP RFS.UNIT Cw. who does such work himself orthmugh his own employees,provided that such
Improver ntsamnotintendedoroffercdforsak.ILhowever,thebulldlegor TOTAL: 91/
Improvement Ieold within oneyearofcompldlon,theewner-bu0derwillhave
Qs.kurden of proving that hedid not Wild or Improve for purpose ofsak.), QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lf I,as owner of the properly,am exclusively mntraning with ur... PERMIT ISSUANCE
contractors to construct the project(Sec.7644,Business and Professions Code:
The Contactor.License Law don not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves thereon,and who contana for such Ex ject.with a
nor(a)Bems, puammtothe Contractor's License Law. FEE SUMMARY
exam der See. B 4 P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• _- " Date RECEIPT X
WORKMANI have aJ ' ION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that I have o certificate of consent to.pythsure,ora RN2EI'I.N
ad11,abctWorken'Cempevatlonlrsuranaoracertllled copythercof(Sec. GAS EA.SYSTEM.1 INC4 OU1LE75 PARK FFM Y N
Polis Isis CJ
Pollry p RECEGAS EA.SYSTEM-OVER 4(EA) DING DI X
Com any BUILDING DIVISION FEES
�CodNed copy k hereby filed
the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
'
Codified copybfiled with the sty Impaction division.
CERTIFICATE OF EX EM PITON FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Chia Bunion need not be completed B the permit is farces hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Retmi tN
($IW)m I..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I arify that N the performance of the work for whish thle pemnit la baud, —
I shall not employ any person In any manner eo as to become subject to the WATER SYSIBM/TREATING
Workers Compensallcn Laws of Gllfornla.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Rett'J tM
Z O NOTICE TO APPLICANT-.Refter making this Certificate of Exemption,you
should become eubjen to the Workem'Compensation provisions of the Labor TOTAL:
CC N Code,you must fort hwith comply with such provielora or this permit shall be BU TNG
doomed revoked.
W O CONSTRUCTION LENDING AGENCY ISMIC FEE
FEE
CL Iherebyafgrm that there Be corotmnlon liniingagenry for the pedorm� LEGTRIG FEE
Z ance ofthe worklor which this permit is Issued(See.3097,Civ.C.) TOTAL: _
U O lander'.Name PLUMBING PEE
U. I— Lendeee Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O Wladifythatlhavcreadthisappllcationanddate thattheabovelnformation
1 iscorrect.I agreeto comply with all city and countymch.ancesand Main laws PERMIT ISSUANCE 'E PA[
>. relating to building com uction,and hereby authorice—p—,........of this
city to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMECH.
Z s
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date - KCCeiptN
V against liabilities,Ptigments,costs and expenses which my In any wayacaue AIR HANDLING UNIT(TO 10,M CFM) SUBTOTAL:
against cad City In conaryuence of the granting of this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hacardou. HEATING UNIT(TO Iffl W0 BTU) Date Recel til
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the
I lealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTI)! TOTAL-
❑Yes r]No
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINCLE RESID) 'MMCE DATE
which emit hazardous air contamsmnts as defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 100,IX0BTU) a
4ave ❑nNo Q b'
have read the haaaWove materiak rcquircments ondm Chapter 6.95 of BOILER-CAMP(OVER 1fU,000 BTU)
the Califomia Health A Safetybuilding
Code, nior=ttl 5,Za a tehnd,than] �
understand( If the the0 gdon Premie an aknang(hath met NEW RESIDENTIAL MECH. - SQFT.
responsibility allytheoavpact the qulrementa which mus he met
P, o imuan aCedlficate olO an ,
Owner or euth agent Date ISSUED BY: a
TOTAL: —
OFFICE COPY