21297 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
j0ftgAddress: 21297
2tocr� SLG �E
a Dev °)1 A CITY OF CUPERTTN0.6UILDING DIVISIONe. rtaeLk.No: APPLICATION IPERMIT 06S BUILDINGELECTRICALPLUMBINC-MECHANICALCATFLORY CONT OL N
/engineer. LIB No:
I -::-rRMIT gi a< •t•,:,-s'i,.! BUILDING PERMIT INFO,?;'o;
/� ./� QTS';:, ,..,.•.ELECTRIC PERMIT :..;„i -'FEE: " -
Address: CL 1 C(,� Qxj , PERMIT ISSUANCE 1:1 E] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l and licensed under provisions of Chapter 9(commune. APPLIANCESRESIDENITAL JOB DESCRIPTION
Ingwith Section 70W)of Dtvbion3 ofthe Bustoessand ProfessionsCode,and my
license isin (orceLaa (ed.5 OL Ca PANELS rs
.Cu � k.p '� U Q�?,be 11-4-s�
Date 10- I Can _1 /. D I �•7 V t s
ARCHITECI•S DECLARATION 211-1000AMPS
OVER 1000 AMPS SQ.FT.FLOOR AREA
ad I understand my plane shall be used a,public records
1300
z yL J Licensed Professimul SIGNS ELECTRICAL
J OWNER-BUILDER DECLARATION
n SI'Ff_LIL CIRCUIT/MSC
owing rasormthaton 7031mpl(somthe Contractors Wcenm Law fort he
QQ ���jjjppp county which regiresa pere1oocansinem and Professions CoaLlshoAny dtyer Tphga MEITR ORIOLE INSF.
Z� anystm mprgrtotaimameal3orect,alteheapmve,der° ch, er ttr
5 any assigned statement
rtqulmsuant t the prer isime,of t e
]OWER DEVICES
file a actor's statement that he b Btenud pursuant to the proviabm of Me
Oma
Contractor's License Law(Chapter 9(commencing with Section
mpethe00)of Din- SWIMMING POOL ELE C- VALUATION
'u, don3ofthe Busbessand Profemior Code)orthe hebesem)Xtherefromand
< the Web for the alleged exemption. Any violation of Section 70315 by any OIIILETSSWIT'CHESFIXTURES
s00 appBtent for a permit subjects thea ppllcant to a civil penalty of not more than
five hundred dollars(SM. NEW RESIDENTIAL ELFG'IR
❑L as owner of the property,or my employees with wages as t W4 ale STORIES TYPE CONSIRUCTION
compenudon,w ldoRhaworkandthestr =mbnot Intended or offered for /
FO sale(Sec 7014,Buatnese and Psofeat Code:The Contredoes License Law ,
�B does not apply to an owner of property who Wilds or Improves thereon,and 9CC.GROUP RES.UNITS
whodae such work hlmselforthwgh his own employees,provided that such
improvement are not Intended or offered for sale.If,however,the building or T
improvementbsuldwithinoneyearolcompletkrytheawnenbullderwW
tl)L4urden of proving that he did not build or improve for purpose ofvle.). QT7';•„ ',S�asSE)PI:LIMBING;PERMIT,,. IsaS1 "',,.FEE{.i FLOOD ZONE APN
L i C as owner of the property,am esdwM1sly contracting was Horma d PERM(ISSUANCE
contractors to..tact the project(Sec 7004,Business and Professions Code:
TW Contredorb License law does net apply to an owner of property who
Wilda or Impeaves therntn, and who camosea foe such pW*U with a ALTER-DRAIN&VENT-WATER IEA)
egnslador(s)Bcensed pursuant to the Contradoes License Law. BACK FLOW PROTECI'.DEVICE = FE.E;SUMMAAY. `a§,riyn'j�`;� 'y
LJ I am exempt under Sec B&P C for this reason
vier Date • DRAINS FLOOR ROOF,AREA,COND. SANITARY RFLhR'I'/
WORKMAN COMPENSATION DECLARATION p ger ppR. a SCROOLTAX Y_ N_
❑I hereby affirm[hal I have a certlOeste of cortmnt[o self-Hare,ora RBC=N
o,rdficate o(Walomt'Compensation I...m a testified copy thereof&(. GAS E.A.SYS[EN-1 ANCA OUT= PARKFEE Y N
3800,Lab CJ
Policy N GAS EA.SYSTEM-OVER 4(EA) DINGR9ZEDF N
Cam any - BUILDING DIVISION FEES
�CenWrd ropy b hereby umbiged. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CertWed copy b filed with the city Inspection division.
CERTIFICATE OF EXEM PFION FROM WOR KERS GRF4SETRAP PAID
COMPENSATION INSURANCE SEWTIF-SANITARY-STORM EA2OFT Date Reoei t#
This section need net be completed ifthe permit is for one hundred dollars
(5100)or less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
1 codify that b the performance of the work(or which this permit la Issued,
I shall not employ any person In any manner n ae to become sub)ed to the WATER SYSrEM/TREATING PAID
Workers'Compensation laws of California.Data
Z Applicant NEW RESIDENTIAL PLMB._SQFF. Date Recei t#
O NOTICTTO APPLICANT:U,aaer rsuWng this CmtBkateof Esempdon,you
should become subject to the Workers'Compatsatlon provisions of the Labor TOTAL:
Yy Code,you nose forthwith damply with sueh provisions orthb permit shallW BUILDING FEE
L > deemed revoked. .
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 IhercbyafB.that there b a msutrudlon lending agency for the perform, TOTAL ELECTRIC FEE
7Z anaofth..,kforwMchlhb permit bblued(Sec.3097,CIv.C.)
J O lander'.Name t PLUMBING FEE
r landersAddress CTiy IVIECFIANICAtiiPEB1NIT 3 FfiH
•'y U IcamilyUrtlhavereadthbapplicatbnandpalelhattheabovelnfomudon rr�� MECHANICAL FEE OD
W bcormct l agree to comply with all city and county ordinancesand state laws PERM(TSSUACE FEES PAID.
} a relating to building Met on and Wrtbyauthorlaertprtmntativesofthb
2 city to ant t ve-mens property(w WpedWnpurperes. ALTFRORADDTOMFLH. �s(,L�
e agree 1 Indemnify an dleep harmless the City of Cupertino Date ReCei (#
V &aloft 1 1 .cis nb,mdsa whkhmaylnanywayacaue AIR HANDLING UNIT 07010,OWCFM) SUBTOTAL:
a tea I ems the nUn of this penult.
/ 0_JC CfO AIR HANDLING UNIT(OVER Io,B)oCFM) 21 rxtQt CONSTRUCTION TAX
/ Signatureo(AppBtent/Contra Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardoes HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
mncrialasdeflm�dbythe Cupedim Muoidpal Cade,Chapter9.IZ.ndthe rr rL
Health and Safety Cade Section 75532(a)7 HEATING UNIT(OVER I00,00)BTU) TOTAL: K s�
71 Yes No
Will theappllont.. turn building occupant use equipment ordevices VENTILATION PAN(SINGLE REBID) Ltc�
. ISSUANCE DATE
hi Will
emit haurdoua air mntambunb as deOrmd by the Bay Area Air w�.
ality Management District) BOILER-COMP OHPOR 100,IXp MU PPM--
Yes No
have read lhehua our materials requirements under Chapmr6.95 of BOfLfRCOMP(OVER 100,000 BTU) OCT „a.,0
the Callfomlu Health Code,Sections 25505,25533 and 2S534. I V 1 0 L�(�
undeutand tFal l(the buildingdaes not mrrently have atenanp thn itbmy NEW R6IDFNTIAL MEC}I. SQ.FT.
rapamibility o notify the occupant of the requirements which mart be met p�
P.
to issuance of a Certificate of Occupancy. 511ty at Cup
Owner or
author
agent Dam ISSUED BY: �{ �l
TOTAL:
• OFFICE COPY