21439-COUNTY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PERMIT NO.
Budding AddreJAI)ss: 21439
. : seri
wne _ 1,sg_ / CITY OF CUPERTINO-BUILDING DIVISION
Costa car Name: Lte.Nce APPLICATION / PERMIT
rc M/ftn neer. BUILDING.ELECnUCAI PLUMBING.MECEIAMCAL CATEGORY CONTROL#
Lk
BI .No:
J QTY ELIfCTRICPERMIT FEE BUILDING PERMIT INFO
" L N / PERMIT ISSUANCE ❑ ❑ �jn (�
LICENSED CONTRunder provisions
RATION — ZON
Ihemby am,7B0hafDN,Jscen3 ofthe erpressand Pre Cssions9(mmmene- APPLIANCESRESIDENTIAL JOB DPSC R'DON
Ingwlth Sed1on7000)of Dlvlelon3 afthe Budnes>and Profeaslone,Code,and my
license l Jl fuR(yce dfeci PANELS
Date ® C:-� LION �s
Date / Contndar —UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
µQ!mZQ I understand my Flaw shall be used as public records. OVERIOOOAMPS 9Q.FL.FLOOR AR' S/SQ.Fr.
E Oc Licensed Professional SIGNSELECTRICAL
<ul '
OWNER-BUILDER DECLARATION
fn SPECIAL CIRCUIT/MLSC
Za, owing reason.
that I Sectio 731.5,B fromthe Ce,stradse.Licenseos Code: ny fee the
following reason.(Secilon 7B11.5,Buainem and professions Cade:My city or
O TEMP METER ORPOLE INST.
PM cnuntywhichetime requites.issuance,construct,
orequialteplmprovgt forsueh,orto
ggg y a any.tmcturc priorto tatemente,that
be is,also and pursuant t the provisionch ofpermit e POWER DEVICES
t4 V (Ile a signed statement that he h,censer pursuant it the tion 7000) of the
3:6 Contractor's License Law(Chapter9(mmnnndng with Section 7000)of Divi- VALUATION
F, Or^ ala.3 ofthe Business it Profemiom Code)or that he V exempt therefromand SWIMMING POOL ELECTRIC
the bash(or the alorgcd exemption. Any violation of Section 7011.5 by any OUTLETSSWITCIffSHXrURES
applicant fora permit subjects the applicant to a civil peialty of me morethan .
live hundred delta.(S500). NEWRESIDENTIALELECTR $Q.ET.
I,as owner of the m STORIES TYPE CONSTRUCTION
�n property, my employees Is
{� compen.atlon,willdothewe,rk and the swdvre b no[Intended or offered for
3� p sale(See.70K Business and Poefenioes Code:The Contractor.Lt..law
does not a pply to an owner of property who builds or Improves thereon,and
who does such work himselforthmugh his own employees,provided that such OCC.GROUP RFS.UNITS
improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement&Bold within oneyearof compldlon,the owner-bullderwlll have
t"tdenofproving that he did notbulld orimprove for purpose ofsale.). QTY; PLUMBING PERMIT FEE FLOODZDNE APN
Lj L as owner of the property,am exclusively=trading with licensed
mntractoes to construct the project(Sec.7044,Business and Pro(eealom Code: PERMIT ISSUANCE
The Contractors License Law dose,not apply to an owner of property who ALTER-DRAIN&VENT-WATER BTA)
roV
Wilds or Improve.therms, and who contracts for such ptajem with a
�q➢t�ador(a)Ilansed pursuant to the Conlmeme.Llmme Law. BACK FLOW PROTECT.DEVICE 'FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reasonOUTSIDE FEES
Ow Date DRAINS FLOOR ROOF,AREA,COND. SANffARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
hereby affirm that I have a certificate of consent to self-insure,or a FIXIVRRS PER TRAP SCIi00L TAX Y_ N
rtitimte of Workera'Compersationlruurance ora certified copy thereof(Sec. RECEIPTN
3800,Lab C3GAS Fit.SYSTEM-]INCA OUTLETS PARKFEE Y_ N
Policy Y os—O 416 O — RECEIPT p
GAS EA.SYSTEM OVER 4(EA)
Com acv_ n za BUILDING DIVISION FEES
�Cedifled copy b herefiled w`ththaceT ~ GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECICFEE
�('7Qrtlfied copy b(lied with the city Impectlon division. -
/`y✓ CERTIFICATEOF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-
(fhleaedion need nor becompleted lithe permit isforonehundred dollar STORM EA.20(IFT. Dale Re I t#
(StIm)orlesh) WATER HEATER W/VENT/ELCTR ENERGYFEE Y N
Ill red employ
oyTo an Pinson I.
any
marche weak for to become
eembus Word,the .� —
1 shall s' employ any person in any manner so u to become eubjeci to the
� Workcr%Compensarlon laws of California.Date WATER SYSTEM/TREATING PAID
ZZ Applicant RESIDEMTALPLMB. SQ.FF. Date Remi t#
Q NOTICETO MPLICt to the
after making rs'Com er .tion provisions
Exemption,you
should become subject mthe Workers'Compematlon provblov ofthe Labor TOTAL:
N Code,you moat forthwith complywith such provisions orthl.permit shall be EUI "E
ILI j deemed revoked. -
CONSTRUCHON LENDING AGENCY SEISMIC FEE
a Ihereby affirm/hat there It a construction lending agency for the pedornr
TOTAL: ELECTRIC FEE
Z anceofthe,work for which this permit hi hwed(Sec.W97,Civ.C.) � civ �V
Lender's APLUMBING FEE
',LL ly — ander.Add aarey OTv: MECHANICAL PERMIT PEG MECHANICAL FEE
O W Imd.Ia neem,comply eapaB cityan county tordinances
aabovedgatellon
IL L.mingt building
mustruwRh all himbleauthorine nanen and gate PERMIT ISSUANCE FEES PAID:
} relat oenterulpontheaboudlndrtlo dpropetyori inspection
n rcprcaenpurpss.thU ,
Z city Weagrecontbeabnverselyaned propertyfor
ewthe Cit purposes. ALTI74OR ADDTOMFLIi. Date Rece1 t#
_ (We)agree to save,indemnify an d keep es which
the City of Cupertino P
against llabllltles,pdgments,"sand expenses which may In anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalrstuld Ci Nmnsequence of the granting of this permit.
—9 AIR HANDLING UNIT(OVER 10,070CTM) CONSTRUCTION TAX
Igrature of Appllca /Conha��J /^ Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppaant or future building occupant store or hs ndle harardous HEATING UNIT(TO l 00,WO BTU) Date RLeeI t#
material a.defined by the Cupertino Munidpal Code,Chapter 9.1 7,and the TT
Health a nd Safety C e n75537(a)7 HEATING UNIT IOg00D BTU) TOTAL: OV
❑Yes
Willtheappllranto future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUAF
which eat hamrdous air contaminants as defined by the Day Area Air
oL��Ilty Maregement Qlss 7 B0ILER.COMP(3HPOR100,000BTU) AN �,H-�I# 1
I Yq �(Iv'a t�f N I-A 91
have read salt ous materialsodSreom 2555,2553 and 255 .I of BOILER-COMP,(OVQt!07,000 BTU) (...
the CaliforniatantHealth& ifetybuilding
Cade, otcurre75505,ve a tenant,
.
.— understand that lithe notify the occupant
of the rhe equire encs tenant,that It met NEW RFSIDEMTAL MECH.' SQT7. _•- ��
morto bilityhoua to e osis/ytheocte of of parry.requirements which most be rtrt /9�1YI
prior to Lssuanm of Certificate ofOmpanry.
0&. �'
ser or aur o and Went Date ISSUEDD
TOTAL:
OFFICE COPY