21651 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
build:,a Purled Identification PERWTNO.
Building Add rtes/ 216 5'1
)OCL; `f 6=L'J' CZ--. k (_'oA . C'i.;/r7T-,•..,>
Pharr:
,owners ante.14 L3 !//' 5-:- rS CIN OF CUPERTIN4BUILDINGDIVISION A , A
Centraeor'.Name: Lic.No: APPLICATION / PERMIT
01V X-2,14/j. 10 � BUILDINGELECTRICALPLUMBINGMWL MCAL CATEGORY CONTROL
rchhect/Engimer. Lic.No:
ktx+ z vmv:axr.+excra:.,.rnl r 1 z„,o s f.,iv-.gUILDING'PERMIT INFO( ',tt�6
QrtELECTIiICPERMI'f ' s �FEE� o ,.eed."i.4•.._ _
Add. PERMITISSUAN'CE �Z,(y ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby mthat lamlicensed!under provisions ofCh (mmmnc APPLANCESRESIDENTUL
IngwthSrctboA7000o(Dlvidm3 oflheBudnstandProfeWdeenCode,and my J BDESCRPIION
limrue 41 fu (. d effect I PANELS
LI¢nse ClestLics�D 3 ��• �-
Date/—II-/� Contractors ' UP TO 200AM'S
ARCHITECT'S DECLARATION 1.1000 PS
oto O I understand my plan W B be used u public records OVER 1000 AMPS /� axyl SQ.FT.FLOOR AREA f/SQ.FT.
Licensed Professional SIGNSELECTRICAL a.}x-(,/
OWNER-BUILDER DECLARATION SPFGWLCIRCUIT/MLSC
?a Iherebyaf/innthtlame.emptfr¢nthe Contntl.ra License Lwlmthe
QQ lolldwing ream.(Betl1m 70315,Btoutu and liofubu Cade:Mytlty or
muntywhichrequlrnapermltWmu Maler,Impr kdem hskornpair
TEMP.METER OR POLE)NSI.
77 anyatma mprl Wit Wuanee,alsorequirnikapphmtfmauchper tto
' file a signed statement that he I.licensed puuant to the o! the POWER DEVICES
rs
MContame.Lie..l.w(Chapter 9(mmmencing with Section 7000).(Di”. SWIMMING POOL ELECTRIC VALUATION
aJm3 oflhe Bualneaand Pro(nab»Code)orthat he besempttherefromaed
the bub for the alleged eaemptbn. Any violation of Section 70315 by any OVILEISSWI•R7iESFIX'NRPS e1,I
a ppU.tf.,.permit.b*e theapphc.ttoadvllpeuitya.m..tMa
five hundred dollars SM. NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
�I,uowner a(tk property,or my employm with wage utktr sale
compensation,will du the work,and the structure b not Wended or offered for
F p ale bee TisµHuslriess ab PMerbu Code:Tk CoMrattors Llcene Law
:nS don not apply tons owner of property who builds or improves themerc and OCC.GROUP RFS,UNITS
who don such work himsea¢through his own employees,provided that such
I ' Improvements are notuttencied or offered fee sale.It however,the building¢ OTAL�ix00,
IImprovement Is sold within one yearo(completion,theownerbu0derwill have _ ,-,,, ygr ��y
•.e., tlV ja am./pmHnglktkdld no bu0d.rimproverorpurpa¢o/ule.). �' ]jjJHjBI MLTs ll3tFE6F3 FLOOD TONE APN
141. 0(as owner of the property,am exclusively mntranlng wfth 11¢nsed
mntrmW
acters to nsct the project(Sm 70K Stoutest and Promilo Code: PERMIT ISSUANCE
3a',c' The Contractors License Law does not apply to an owner of property who
) r bud"or Improve,thereon,and who contract for such pit, with a ALTER DRAM&VENT-W
;'g ntorW licensed expursuant to the Cmtract¢b ggpp Lt..Law. !W. m RtEsUMMARY:J_ %N
_ _... ._ _.
Lj
I am empt under Sec B&P C for this reason BACK FLAW PROTECT'DEVICE ,
DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N_
- -* Owner Date RECEIPT I
WORKMAN COMPENSATION DECLARATION� F0(ISIRES PER)RAI' SCHOOL TA% Y_ N 3�hereby affirm that I have•certlBcate of consensu ¢
t to self-Insure,or RECI7PI Y
rtBi¢teofW.rkenCompenutlminsuran¢¢a¢rtllkdropythereol(See GAB-EA.SYSTEM-1INC4OUiLElS JP"_FEE Y_ N_
�bc3G H"18 FOcuv �3 RECEmrx
CAS EA.SYSTEM-OVER d(EA)
Cram BUILDING DIVISION FEES
rtl(ied mpybherehy famished. GREASEANDUSRil WASTE INTERC TN2 PLANCHECK FEE
CertlBed ropy b(Oed with the dry Inspection dlvielm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANrrARY-STORMEA 7BOFT Date Recel ted
(D easeGian cared not he completed Rek perndt b f¢or�e hundred dollen
(f100)mf®d WATER HEATER W/VENT/ELFZTR ENERGY FEE Y N
I cesuct thatin othe person
of thewank so as
permit ubjbblued,
I shag not empty nay person f any manner w u to become subject to The WATER SYSTEM/TREATING
W¢Appli n Campenutbn Lsys of Ca11lomb.Date PAID
Z NOTICE( NEW RESIDENDAL PLMB._SOFT. Date Recti tit
NOTICE TO APPLTCAM:a after making this Certificate of Exemption,you
should become subject[.the Workers'Compensation provblon.(the Labor TOTAL,N Code,you== atlhwlth mmp"th such provisions orthb permit shall be
5 .d¢r¢dtevS.ed. 13UILDING FEE
C �_/ CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat then b a commuctlon lending agency for the perform- ELECTRIC FEE
O uceofthework(orwldchthbperrrdtbesmed(See3097,CIv.C.) TOTAL
1 mcloe.N. ,,....� <..,-__..__.... ,... ,a.._,... . .sr_ ... PLUMBING FEE
F_ lan ice.Addles OTY. !•,„:MECHANICAL{PERMIT ';? s:ti'kFEE?es MECHANICAL FEE
WI¢dlfythatlhave WthbappBatbnaMrtatethetheebave N/omuti
C bmrmtl.I agree to camplywlth all city and muntyoedlnances and 9:71.112 PERMIT ISSUANCE FEES PAID:
U) rclatingtobullding mm(morm and herebyaathorlae representatives ofthea
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,IndemNly an d keep harodest the City of Cu pertleo Date Receipt#
agaWt
liabilities,0 dgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
ga/mt mid City ut consequence of the granting of this permit.
qq AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
—e-I A` n" ca w. /-1 it� CONSTRUCTION TAX PAID:
Signature o(A EonARDOUS Date EXHAUST HOOD
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.1 future building occupant store or handle hazardous HEATING UNIT(TO I M,000 BTU) Date Recei t#
material as dcb ned by the Cupertino Municipal Code,Chapter 9.1 7,and the -
Iical(hand Safety Cade Section7S537(a)7 HEATING UNIT(OVER i 00,000 BTU) TOTAL: i t
Yes No
WBlthe eppliont or future building occupa cat use equipment or d evices VEA"IILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haurdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR IM000 BTIn
P Yea i
have rtad the hazar`,&#I rooteclat requlnmentsunderCkpler 6.95 of BOILER-COMP(OVFR IW,OW BN)
the Caldarnb Health&Safety Code,Sections 25505,75S33 and 75534.I
understand that if the building does not currently have a tenant that it is my NEWRFADFNTIALMECH SOFT
responsibility to notify the occupant of the requirements which must be met IqQ
prior to buance o(a Certl/Tote Vf Occupancy. L 9v
�ti� °11-1alGfioHi.r /—n-yi 1
Owner-1-ifili.11mil agent Data ISSUED
TOTAL:
OFFICE COPY