21077APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
HuOdilg yddress0o 51-eoPpjs c,eeF'
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PERMIT NO.
- 21077
ne
.(�aImeane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTMCAL-PLUMBINGMECHAMCAL
p
-2-�'- -6
C am or :Lk,lx.
�b ISS
CATEGORY
CONTROLN
Arc Iteci/Engineer, Lk. N.
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
'
Addram:
PERMITISSUANCE
El ❑
LICENSED CONTRACFOR'S DECLARATION
I hereby affirm that l am licensed under provklonsof Chapter9(cmmcno-
ingwit ISI ful form anDieffect aftheBwineeand Pre le.eloneCade,and my
❑Cense b in ful force and c. 0'
License Chss=_Co N
APPLIANCMRESIDENf1AL -
JOB DFSCRE'IiON
��
PANEIS
Date Contractor
201-1000 AMPS
ARCHITECT'S ECLAR TION
I understand my plans shall be used an public records.
OVER 1000 AMT'S
SQ. Fr. FLOOR AREA
S/SQ.FT.
SIGNSELECTRICAL 1
Licensed Professional -
OWNER -BUILDER DECLARATION
1 hereby a(@m that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/MISC
TEMP. METER OR POLE [NST.-
following reasoa.e3ectfon 70115, Business arad Professions Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair
r
anyslmcturs prior!oits Issuance, also requirmthe applinntfor such permit to
(Ile a signed statement that ha Is licensed pursuant to the provisions of the
Contractors License Law ("pier 9 (mmmendng with Section 7000) of Dlvl-
skn3 o(the Businem and Pros emlmu Code) mthst he is exempt therefromand
POWER DEVICES
t
SWIMMING POOL Fl.EC C
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit Subjects the a pplicant to a civil penalty of nM mom than
OUTLETSSWITCIILSFIXTURES �f}} i
NEW RESIDENTIAL ELECTR. k�l tl a
bSQYT IL
five hundred dollars (SM,
❑ 1, as owner of the property, or my employees with wages as their sole
compemation,will dothe work andthestrucrore b not intended or offered for
sale (Hee 7044, fluidness and Professions Code: The Contractor. Llcense Law
STORIES
TYPE CONSTRUCTION
) `�i� .y l
t V
docs not apply to an owner a property who Wilda or improves thereon, and
who doessuchworkhimsel(orthrough hlsownemployees, provided that such
!'*
0
C. GROUT'
RIS. I1NfT5
improvements arc not Intended oroffereifor sale. If, howcvep thebuilding or
Improvement lssold within oneyearofcompletion,the owner-bu0derwill have
Ya N TOT v
ft-ilrrden of proving that he did not build or anprove for purpose of sale.).
[_J I, as owner of the property, am exclusively contracting with licensed
contracture ss to construct the project(Sec. 7044, Business, and Professions Code—
The Contractors License Law does ant apply to as owner of Property who
builds or Improve. thereon, and who contracts for such p(oject, with a
�qtt etor(a) llrensed pursuant to the Contractors License Law.
LJ I am exempt under Sec. H & P C for this reason
QTY. .PLUMBNGP T FEE
PERM UANCE�
ALIERA- IN &'VENT -WATER (EA) t
HOOD ZONE
APN
gACKFLO PR"O7ECT. DEVICE
FEE SUMMARY
FEES
DRAINS RfROOF, AREA, COND.
FDCrURE!3_PFR
SANITARY Y— N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION a"diffse DECLARATION
❑I hereby that I have an of consent to ora
SCHOOLTAX Y— N
orfirmkers o Insurance pytheare,
3800 ate of Worken'Compensatlonlnsunnre ora certified ropy thereof (Sec.
3800, LabC) �// (► Z
I'oliryp N/i-��f.% D
RFOFR'T N
GAS EA. SYSTEM-]INC.4 OUTLETS
PARK ITE Y_ N
ftECER'I'N
,J2
Com env
GAS LA. SYSTEM -OVER EPA)
BUILDING DIVISION FEES
Certlfled copy rs hereby furnished.
Certified copy b riled with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
. CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE hundr
frhca section need not lithe ppermitV /Drone ed dollars
PAID
Date Remi t#
_
SEWER-SANITARY-STORM F.A. 20071'.
(ft Imnify that
I cent that In theperformance
r in an tmarearhe wast tforwhb ecomhis emdHe ho the
person
I .hall not employ any person In any manner m u to become Subject to the
WorkcCompensation Laws of California. Date
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
WATER SYSTEM/TREATING
Applicant t
NOHCETO APPLICANT: IL after making thin Certificate of Exemption,you
should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions orthk permit shall he
deemed revoked.
Date Remi til
NEWRESIDENTIALPLMB. SQ}T.
TOTAL:
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihembya(Rrm thatthemisa construction lendingagenry for the pafomf
ante of the work for which thio permit V Laued (Sea 3097, Civ. CJ
TOTAL:
ELECTRIC FEE
Landers Name
Lenders Address
( certify thatl have read this application and state thattheabovelnformation
is correct. I agree to complyw haH city and roomy ordlamom and state lave
-
QTY. MECHANICAL PERMIT.' FEE
PLUMBING FEE
��99
PERMIT ISSUANCE � p
MECHANICAL PEE
00
FEES PAID:
relating to building.. truR on, and hereby authorize representative of thla
city toupont-.bov- ntloned property for inspection purpose..
e) agree to save, Inde Ily an d keep harmlem the City of Cupertino
aga stliabllitie,7udg ntscmm. .parses which may In anyway accrue
ag nut mid i Aro ce r granting ofthls Permit.
ALTERORADDTOMECH. -
pate Recef tN
P
-
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 101000CFM)
CONSTRUCTION TAX
of ppli t/Contractor Data
FX D (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TOI ,OOO BTU)
Will the applicant or(umre building occupant store or handle hazardcua
material as defined by the Cupertino Municipal Code, Chapter 9.1 A and the
Ifealth and Safety Cod a SeRlon 25532(a)7
❑ Ye , 1+�—} -
Date Reeef tli
TOTAL:
-
HEATING UNIT (OVER 100,000 BTU) -
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
Pft
Will the appilaof dMnare building occupant use equipment or devices
which emit havardous air wataMwnt. a. deRned by the Bay Arca Alr
Quality Managementistrict7
Yea No
4havlcredthebaz
BOILER -COMP ORP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
rnmerials requirements u ader Chapter 6.95 of
the Celrnla Health & Safety Code, Sections 25505,25533 and 2:534. 1
NEW RESIDENTIAL MECH. SQ.FT.
understand that ifthe bu' ding doe not currently have a tenant, that it is my
.n
mapo Ility to nceifyl a occupant of the requimment.hlch mmmrrrrm��#i he met
prior Issu ncc o(a Ce I(kate fOmpanry.
'f-i'��W+�IiI�M!
ISSUED HY:
Owns au geDhte
r'
TOTAL:
OFFICE COPY