21656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identlflcmlon ; l D� /y G - PERMIT NO.
Building Address:� �i` Y\ [ ^� �a�
B 47L7 SlGvE V25 G J`
ncra sine: ,/ one; - A
"atl X50 dhe Ve/QL CITY OF CUPERTINO-BUILDING DIVISION
. ran°' Name: a t1ieN APPLICATION /PERMIT
S ✓ llr ��
Architectgf / Lk.No: BLULDING-ELECTRICALPLUMBING-MECFIANICAL CATEGORY CO I'jIC)Ly_.0t,(b
��/ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addm� S' /M� (/�� PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARAT N .
(hereby aEmuthat l am licensed under president,of Chapter9(commmc APPLIANCESRESIDENTIAL 708 DESCRIPTION
ingwith Senion7D00)of Dlvision3otthe Businenand Professions Code,and my
license le In fu d died,64 ; PANELS
LlmnuC n LIC M_ctor �7v70 /i'�l
Date ! Conmanor —UP TO 200 ANTS
ARCHITECTS DECLARATION 201-I01TOAMPS
el Z I understand my plain shall be used as public records. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O SIGNSELECTRICAL A L E D i
- � Licensed Professional
Q OWNER-BUILDER DECLARATION
I E
Ihereby affirmthatI am exempt from the Contractor's License Law forth¢ SPECIAL CRCU T/M SC
Q Q following reason.(genion 703L5,Business and Professions Code:Any tlty or
rzt'"'� ceuntywhichrequiresa permittommttunalter,Impmvemo
,delbhM p T
,ormpalr TFMIP,MEfLR ORIPOLE INSf. L
�gg anystmcture pdorto its laeuance,alernequiresthe applicant forsuch permltm POWER DEVICES $ 1p/� /
rNE 0.S Bin a signed statement that he h licensed pursuant to the provhbra of the C
Contractor'.License Law(Chapter 9(commencing with Section 7000)of Divi- EBe
alun3ofthe Business and ProfesslorsCode)orthat he is gWEs{,XgNG POOL ELECTRIC exempt - _ •VALUATION,
0 S the bash for the alleged exemption. Any violation of Section 7BIIS by any OUTLETSSWITCHESHXTURES �U Q a
applicant for a permit subjects the applicant to a civil penalty of not more than
Q five hundred dollars($500). ��,
NEW ftLSIDENI7AL ELECTR
�n ❑I,asowner l of property,or my employees la with wages r ffer sob STORIES TYPE CONSTRUCTION
cm pec.70K Business andhe rofessand hes Code:The
Coomaat ndedormmeL(urw
O sale(Sec.apply
to Business and f property Cade:TM C Improv/e Llceme Law
$ don notapply roan owner ofpropertyhisobuilds nemorlmproveted that such
F'$^
who does such work himself ortM1rough hieownemplayen,presided thatevcM1 OCCGROIIP RES UNITS
impro ,uncea are not intended oroffered foreale.If,however,the W llding or TOTAL: 0 fl
impmvemenrhaold wlthtn°neyearotcompiniorythe owner-bullderwlll have
tlVLLmrden of proving that he did not build or Improve for purpose clank.). QTY, PLUMBING PERMIT FEE FLODDZONE APN
G ae owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contactors to construct the project(Sec.70K Business and Professions Code:
The Contractors License Law does nor apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improve thereon,and who contract for such pwjeals with a
o�Blfanor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICEFEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
OUTSI DE Hill S
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date• WORKMAN COMPENSATIONRECE PT#DECLARATION
E31PER TRAP SCHOOL TAX Y_ N_
film I hereby effithat I have a certificate of consent to self-Insure,ora RECEIPT#
39M,Lab
C.) S aC.Werkere Cemperxsatlonlmurance oracertlfled copy thereo((Sec. GAEA.SYSTEM-I INCA OUTLETS PARK FEE. Y N
P.Iky3BOq
Ciurn N GAS EA.SYSTEM-0VER 4(EA) RECEET p
CLjjCeY B U I L DING DI VI SION FE ES
IaTMiBed copy le herebyfurnished.ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI IECK FEE .y3j
()cam–'7'ltifled copy is(lied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION erINSURANCEPAID
SEWER.SANITARYSTORM EA 200F1, Date Rl t#
(Thlaeection need not W mmpined If theeppermitth(Drone hundred dollars epeP
($1 I orrify that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify thato any phe erson
the work an as to in
permit Is Issued,
I shag not employ any L.. f any manner at u to _ K the WATER SYSTEM/TREATING
Worlicra'Compensat(on Laws of Glifomk. Date PAID
O Z NOTICE
Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recd t#
Z O NOTICE co MPLICAM:a after making this Certificate is Exemption,you
should become subject to the Workers'Compensation provisions of the Leber TOTAL:
P:
W Code,you must forthwith comply with sued provisions or this permit"(be BUILDING 62. 00
j deemed revoked.
dO CONSTRUCTION LENDING AGENCY SEISMIC FEE tie
I hereby afRrmtbut there b a construction lending agency for the perform- ELECTRIC FEE
Z anceofthe worktorwhich this permit hIssued(Son.3097,Cie.C.) TOTAL' .00
02 Lender's No. PLUMBING FEE
LL 1- Lender.Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W l certlfythat l have mad thbapplleatknaM antethat the above information
b current.(agreeto complywlth all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
O' relating to building construction,and hereby authorUe representatives ofthis
F fA city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? Me)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against lhbllities,Ndgmeats,costaand expenses which may oywayaoaue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
agalnabald City In cons nceo (h anti tM1ls pc 1.
7 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
h
Signature of Appllant/Contractor to EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle harardom HEATING UNIT(TO 100,000 BTU)
materiald defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recej t#
I initis and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL- 4
F1 Y. r]No
Will the applicant ortfuture
cont building an defined
ndby theequipmentArta devices VEMfILATION FAN(SINGLE RESID) ISSUANCE DATE
which eMahagement It contaminants nanh as defined by the Bay Area Air PAID
Quality Management DuMn7 BOILER-COMP pFEPOft 100,IXD BTU)
Yes n❑No
have read the haaarc us materials mgWrcmentsundei Chapter 6.95 of BOILER COMP(OVF7{lOD,fR70BTU)
the California Health&Safety Code,Seniors 25505,25533 and 25534, I MAR -9 1891
understand that ifthe building does not currently have a tenant,that it b my NEW(RESIDENTIAL MEIN. SQ.IT.
responsibility to notify the occupant of the requirements which must be met \/
prior to issuance of a Grtiticate of Occupancy. #aj{aa aaf Y:
/aurpo'A(0
Owner or authorized agent Date YY1Na YN�t-
TOTAL:' IISSUEDBBY:
OFFICE COPY