21600 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE SALL POINT PEN ONLY'
Building Project Identification - i PERMIT NO.
Building Add rem: 2L'^ 21600 ,
�O«Q Su i S u v-), � ,
cote:c
'wners = one - A CITYOFCUPERTINO-BUILDING DIVISION
2^n°% / ! APPLICATION / PERMIT � o
°y^�n�aL` �
J�f/ ICSaNa^�e.CSC'I at— U iOrO ZZ / BUILDINGELECTRICALPLUMBINGMECIIAMCAL CATWORY CONTROL N,
Architect/Engineer. _ - Lic.No:
;iter ;i 'k[,;ELECTRIC PERMIT,At i� I,�FEE`� !�"0t,'B,UI4D(NG,PERMIT-INFO,
Address: PERMITISSUANCE l []
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IJ1J LIJ
stE
Ihereby affirm that l am Bcrosad under provWons of Chapter 9(commm JOB DESCRIPTION
Ingwith Sectio^7000)ofDiWslon3ofthe Businessand ProfaislonsCode,and my a'
license le in full force and effect. - PAM1S f .�
LicenseCie. Lle.N I �� Tal— •Data Contractor
ARCHITECT'S DECLARATION 201-1000AMPS
77 I understand my plane shall be used m public records. 'OVERIOl0AMPS, SQ.FT.FLOOR AREA S/SQ.FT.
tis bu Licensed Professional - SIGNS ELECTRICAL -
GGQ --assaaa lag
OWNER-BUILDER DECLARATION
7�pyj Iherebyafflrmthat l am exempt fmm the CentrSaorb License Law for the SPECIALCB{CU17/MISC � f,
following reason,ISectlon 7031.5,Business and Professions Code:Any city or
O7r� TEMP.METER OR POLE INST.-
countywhlchrequiersapermUtomnstruct,alter,improve,demolish,orrepalr _ _ -
anystructureprior toIts issuance,also requlreathe appllant for such permit to "
file a signed statement that he la ['OWER DEV[licensed pursuant to the provisions of the ,
Contractor.License Law(Cha(Chapter 9(commencln withSection
ptsn n B SWIMMINGPOOLELECIRIC L,
slon3o(ihe Buelnem and Professloro Code)orthai he lseum there(romand ^ VALUATION
6 s the bass for the alleged exemption, Any violation of Section 7m L5 by any OUTLETSSWITCHFSFIXTURES
Q applicant for a permit subjects the applicant to a rnll penalty of not more than
five hundred dollars(5500).
L as owner of the roe NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
property,ky,or my employees with wages r thele sole x
t- c 1.&c.7on,B.ttiowill exandthe Professions
Code:Tructure bn Contractors
ormmeLaw
j offered for
0 does
notapply
to anow owner
of property
Code: or Impourves dori Limen and
law
(j$$ whodasuch manownerofproughhisonempaym,prvided mquch - OCC.GROUP RIS.IINTTS'
C: wprovemnts are not msededomugh hieow aleph owevezovldedthe ildithat ouch _
Improvementsarenot lntendneyeartemdforsale.theonvegflder ilIhave TOTAL: L
, Improvementbwld wlihlnoneyearo(compldioMtheowncr-bu0derw111 have
ttas rdenofprovingthathedid notbuildorimpmveforpurposeofsale.). QTy�' "•� ",t,iPLUGiP
IUM R MIT}•=x ,;L it'�t FEE,
61' HADD TONE APN
1, owner of the property,am exclusively contracting with m
Iiceed I PERMIT ISSUANCE - I-1 -
contractors to cotslruct the protect(Sm.7014,Business and Professions Code: 00 -
The Contractor's License law does net apply to an owner of property who
Wilds, or Improves thereon,and who,contracts for such p{ojecta with a ALTER-DRAIN&VENT-WATER(EA) -7, -
',Il M
etor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE a ' ��r FEE,SUMARYt,
IJ 1 am exempt under Sec. B &P C for this reasonOUTSIDE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N .
EES
Owner Date t RLCEIIII'N
WORK MAN COMP ENSATION DECLARATION• FIXTURES PE mkp //1�s, SCI100L TAX Y_ N�•
❑I hereby affirm that'[have o Insurance
of acarri to copy
thereof
or . RFCEIIIT N
38W,Lab ofWorkera'Compevailonlwuranre orarerlfled copythereof(Sea GAS EA.SYSTEM-I WC.4 OUTLET � PARK FIE Y - N_
Poli lab CJ - .
Is
C tm any GAS EA.SYSTEM-OVER 4(EA) B U ILDNCCDDI VI SION FEES
shifted copy 6 heed with the
GREASE/INDUML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is here y furnie city Inspection division.
CERTIFICATE'OPEXEMPFION FROM WORKERS' GREASETRAP - PAID '. 1•
.'COMPENSATION INSURANCE gEWER- STORM"-SNRM FA XIOfrI• y• DBIC RCOCI t# '
(Thissection need not be completed if the permit la forone hundred dollar
(5100)oesx.
tifythat In the performance of Mpermit e work for which this peit is lased, WATER HEATER W/VFNT/ELECTR ENERGYFEEY N
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING i -
Workers'.Compeneatlmn Laws of California. Date- PAID s
Z Z Applicant t NEW RESIDENTIAL PLMB. SQ.FT. Date ReceI t#
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become aubject to the Workers'Compensation provisions oflhe Labor - TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be
W > deemed revoked. - _ G FEE
CONSTRUCTION LENDING AC ENCY a SEISMIC FEE LIG
CL I hereby a fflrm that there la a mostrualon lending agency for the perform -
Z 'IOTA[: ELECTRIC FEE L
anceotihe work this permit (Sec.3097,CIv.CJ {.e..1[/
U O Lender'aName PLUMBING FEE
H Lender.nddrom - QTY. �''t MECHANICAG'PERMIT, FEE
LL MECHANICAL FEE
OWiscurect.I agreehave read pty withapplicationaand tlaty ordinanceshat the a Information ' '2cr FEES PAID:
a contract.la recto empty on,all til and county ordinances state laws PERMIT ISSUANCE -
} city
covwaierymdhereby authorizercction put
of this
cit t mere on tve,indcunify an
f inspection portion
LTER OR ADD TO MFCF{. Date - Reeei Ht
{� Z Y°e P Property for supe purpo �(f(�
(We)agree to cove,Indemnify an d krep harmless the City of Cupertino
V against llabilltlea,;udgments,cosh and expenses which may In any way AIR HANDLING UNIT(f010,000 CFM) � SUBTOTAL:
pgalnat said City In ronaequenc fibs�rening of this permit - .
< � ` AIRFIANDLINGUN1T(OVFRI0,W0CFM) CONSTRUCTION TAX
1-7
Slgmturco(Appilant/Contractor Data EXHAUST HOOD(V/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 't '
Will the a ppileant or future building occupant store or handle hazardous HEATING UNIT ITT)IDg030 BTU) Date RCCCI IN
material as defined by the Cupertino Munldpal Code,Chapter 9.17,and the - �-
I❑t yea
d Safety Cade,Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) :TOTAL: ITG
No
Will the applicant orfuuNmbuildingo pantumequlpmentordevicus VENTILATION FAN(SINGLE RESID) ISSUANCE DA'Z'E
which emit hazardous air contaminants as defined by the Bay Area Air -
QualityManagement Dlstrlct7 BOILER.COMP(3FR'.OR 100,DM BTU) ,
n Yes n❑No
"Fhaveread the hazardous materials requirementsunder Chapter 6.95 of BOILER-COMP(OVEt 100,000 gill) -•6jpR
theC lifornlaliealth&Safely Code,Sedions2550.5,25533and2S534.I _ 16,�fI
understand that if the building does not mrrently have a tenant,that it is my t NEW RESIDENTIAL MECFI. SQ.p..
responsibility to notify the ocmpant of the requirements which must be metcCGT ay /) •991
prior to issuance of a Certificate of Occupancy. I-/F. V !�J(s7�'����'�y�
Owner or authorlud agent Date1 ISSUED BNF
TOTAL: k �0
OFFICE COPY