21555 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building project Idemlfication - - PERITNO.
Building Address: }I' 3 I�� - - 21555.
1126"1
Wneradeet: one:'
B��S ' CITY OF CUPERTINO-BUILDING DIVISION' 1-) -1:r_gO
cn radc".NaUIme: Lie.No: APPLICATION I PERMIT
BLDING.ELECTRICALPLUMBINC MCCHAM
CAL CATEGORY CONTROL N
'� Arch sect glneer: Lie N.
- Qry i -I ELEC71CPERMIT i ,T ,.,l ?')FCC .I `-11 ',:BU[LDING PERMIT INFO1. _
Address PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION_ Ingwlth Sedion7ODO)of Ml sion3ofthe BuslnessandP fcasonaCode,andery,
license b In full force and effect /[ f PANELS
a.Class Lle.. &PT02OO WE -
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
µQS Ore O I undenttand my plans shall be,used as public records. OVER IOOO AMPS SQ.FE.FLOOR AREA 9/SQ.FT.
E Licensed Professional, SIGN LEOTRIC4L
OWNER-BUILDER DECLARATION SPE(_ IRCUT/M
7p„ & 1herebyaffirenthat l am exempt the Contractor's License Law forthe
oo following ma n.(S ire 7631.5,Bdsin...d Professions Code:My dty or
02s. TEMP.ME OR INSf
p anycpustructure
requltesa assuantoronswuire@ the applicant
for such
to
gSI�y anystrudvre prior to lb lawance,also rcqulreerhe applicant forsuch permit to ppyp�gD I
L5 r0G d 6 Ble a signed statement that he Is Bcensed pursuant to the powbioru of the
Ok Contractor'sLicense Low(Chapter 9(commencing with Section 70()MofDivi.
H�O� Mon3 ofthe Business and Profemb.Code)or that he is exempt therefrom and SWIM,WNG L VALUATION
the beats for the alleged exemption. Any violation of Section 76715 by any OITILETSSWHCHFS FS
applicant fora permit subjects the applicant to a civil penalty a not rrore than
five 1.
1,as
owndoler
of heji($50). NEW RESIDENTIAL ELECTS SQFr. STORIES TYPECON91RUCIION'
c ae owner o d t property,or my employees wlih wages r thele sole
7Q rompcnsaHon,wBldothe work and Professional ructure Code:The
Contraot ndedo License
Law ,
q dile(Sec. ppy to an
fproperty Cobuild,or Impctols Lroses ereon Law
3$
who deadoes net s
sack roan owner ofp rough who Wlmoyees,povidedthatand - OCC.GROUP RIS.UNITS
whodoementsworkhimselfetdedoroughhlsoroffired rs employees,
Improvemcntbmld are notintendedthe o eebuflderM]ln ve TOTAL:
Improvementbsoid withlnoneyearo(Completion,the owner-bufiderwlll havethe burden of proving that he did net build or improve for purpose of sale.). QTY, LJMBING'PERMIT,',-,. - Iu,,FEE" FLOOD ZONE , .AEN
L1 L as owner of the property,em exclusively contracting with licensed PERMIT ISSUANCE'
crntractws to moslruct the project(Sec.70K Busmen and Professions Code: [�.� -
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 6 VENT-WATER(FA)
Wilds or Improve theme,and who contracts for such paojects with a , I I '.'FEE SUMMARY
ro[,R5[�actar(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTFOT.DEVICE �r.
LI I am exempt under Sec. B k P C for this reasonI OUTS 11 311 hES
Owner to
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
_ DaRLCEBzf
I WORK MAN COMPENSATION DECLARATION p
FO(TURRSS PER TRAP SCI IDOL TAX Y N
❑E hereby affirmorken that 1 have o Insurance
of consent to op thereof
or RECEBxr N
MOOjate bC.) rkeri Compensatlonlnsuranre ora certified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Poilry p RECEDING DI p
GAS EA.SYSTEM-OVER4(EA)
Com any BUILDING DIVISION FEES
Codified copy is hercbyfamished. .� GREASE/INDUSIRLWASMINTMCEPTOR 2 PLANCHECKFEE
ff
Codified copy is filed h;mbylthtM city inspection division. 1� -
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP
PAID
COMPENSATION INSURANCE SEwFR-SANITARY-STORM EA.2fion Date Recci t#
' (Chis section need not be completed if the permit is for one hundred dation
($100imlen.) ' werFRhFATxw/vENT/ELVR ENERGY FEE Y N
I certifythal In the performance of the work for which this permit is heed, —
I shall not employ any penton In any manner se,as to become subject to the - WATER SYSTEM/TREATING
Workers'Compvooti.n Lawsof Cahfmma.Data - PAID
O Z Applicant - NEWRFS[DENDALPLMB. SQ.FT. Date Rete[ t#
Z Q NOUCETOMPLICANT:If after making this Certlficsteof Exemption,you
should become subject b the Workem-Compevatbn prevbbm mf the Labor TOTAL:
CC W Code,you must forthwith comply with such provisions orthis permit shall be
W G deemed revoked. BUILDING
FEE
UjCONSTRUCTION LENDING AGENCY .SEISMIC FEE -
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
7 Z ance of the work for which this permit b issued(Sec.3097,Clv.C.) TOTAL: t
02 L.endeea Name -I, PLUMBING FEE T610
U. Leadce,Add. QTY, MECHAN_ICAL'P_ERMIT FEE' MECHANICAL FEE
O W Icertify that[have readthls applicatlonand statethat theabove lnformrutlon
U correct.l agree to complywith all tltyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. a relating to building construction,and hereby authorlu representatives ofthLs -
(— N city to enter upon the above-mentioned property for irupection purposes. ALTER OR ADD TO MECH. ,
? '(We)agrrem xave, aadkeap Earmiem the City of Cupertino Dale ReCe1P[#
V .ga
lnstI bill? ,rydgme ,costa en ex Ich mayin anyway... AIR HANDLING UNIT(TO I%OEa CFM)
SUBTOTAL:
eget IdC In con (the granlingo t It.
AIRHANDLING UNIT(OVER IQ,000CFM) CONSTRUCTIONTAX
slgnx Date EKHAUS'r HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS RE
'Will the applicant or future building occupant stomor handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - _
ITcalth'and Safety Cale�x-S�ection 25532(.)? HEATING UNIT(OVER 100,000 BTU TOTAL: s �
E3Ym I�No ..
Wllltha applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RFSIU ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Ilty Maiagement District? ' - BOILER-COMPDIE'ORIO0,00OBTU �qR�
.yes g Na i�'OODU
haveread thchavra'm matedabrions2rrcntsundeand 2554. 1 of BOILER-COMP(OVI]i lIXI,f100 BTU)
theCalifornia HealthAildin Code,Secturrenttly have 33 a tenad255M. I
understand that tithe ify the
building not therequirements
haves tenan4 that It me, NEW RPSIDEN77AL MECH. SQ.Fr.
priors Ess a ce of theoccupantofthercqulmmems which must be mrd
prior to Issuance ofaCertificate of Ocmpanry. '
�nlc
Owner or authorized agent Date -
TOTAL: ISSUEDBY:
„ OFFICE COPY