21972 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
11.11,11.g Project Identification - PIILMITNO.
Pfullding Add S,: Aar J _ .. „ 21972
'
wnere ante: F, Planar: -
_ .(' CITY OF CUPERTINO-BUILDING DIVISION A
Comractorg Name: Lk.Nn: - APPLICATION / PERMIT
BUILDINGELFGTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL p '
Architect/Englneee Lk.No:
t' ".A"BUILDINGTERMITINFO
QFy',, ELECTRIC PERMIT t. t�FEE 1 - -
Add. ICE ..
PERMIT ISSUA ❑ ❑ l �1
LICENSED CONTR under BDECns of Ch ON - - IION
IMingwiflisrodo lrmthatleivieM30(theB ,i.,.nnsof Chapter9(comment, MPLIANCGSRFSI)ENTIAL JOB DESCRIPTION
(conch iriiffifor )ofdeffeon3 oltheBmine.aand Profeulona Code,and my
license 1,in toll lone and e((ett.
PANELS 1 • `�
License C6m Lk.p �.�J
Date Contracon
ARCHITECTS DECLARATION 201-1000 AMPS
pkp�vv on Zp Itudereandmyplaru,hsBMusei aspubEcreence. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.-
L (Cj Licensed Profcsslowi , ; I _ C SIGNS ELECTRICAL
�<<.4 OWNER-BUILDER DECLARATION $FICIAL CR2CUIT/MISC
71, 7 (hereby affirm that l am exempt from the Contractor's License Law for the ,
Following reason.(Section 7031S,Business and Professions Code:Any city or
iOZ a'u9c ntywhlchrcqulresapermittommtmd; ter,lmptove,demollah,orrepalr TIME.MMTR OR TOLE INSC.
p"��I anystructure priorto its lsmanee,aluorequireslhe applicant forsuch permit to - POWER DEVICES
file a signed statement that he E Ikensed pursuant to the provision,of the
u, Contnctor'a License Law(Chapter 9(commencing with� Section 7 )ofDivl-
0 ,lona ofthe Business and ProfessimuCode)orthat he is examptthemfmmand SWIMMING POOL ELECTRIC VALUATION
6 the basis for the alleged exemptinn. Any violation of Section 7031.5 by any OUTLETS5W[TCHESIgXTURES,. ,
( ,pplicant for a'permit sub)ects the applicant to a civil penalty of not more than
F q five hundred dollars
($500)" 1 NEW RESIDENTIAL ELECTR '
�Laaowner, preeperty,work,a d myeucture nwlthwagn as sole fo `•'Q'IT• STOWES TYPE COh'STRUCl10N'
compensation,7044,w0lda the work,and the structure V not Contactor or offered sloeLaw
a q vie(Sec.704y Busbiese and Iarafesslbris Code:The Contracipte Lireree law
does not apply to an owner of property who builds or improves thereon,and OCC GROUP RFS.UNITS
whodonguchworkhtmselforthreugh hlsoweemployees,provided that seach
Improvements are not Intended oroffcred for sale.lf,however thebuilding or TOTAL:
Improvement bsoldwith(n oneyearolcompletion,theowner-bugderwill have - -
the burden of proving that he did not build or Improve for purpose ofsale.). QTY, �;'' ',TLUMBINGFERMlTe10,'v : ' FEE, ,- FTADDZONE ALN
' 1 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 1�
contractors to construct the project(Sce.70K Basineu and Profession Code: � l QC�,
The Contractor's License Law does not apply to an owner of pmperty who ALTER-DRAIN&VENT-WATER BEM
or Improve.thereon,'and who contracts for such pkojects with a
'
cLJg11[factor(q licensed pursuant to the Contractor's License Law. gpQ((plpyy PROTECT.DEVICE ,tt' t �i FEESUMMARY `
I am exempt under Sec B&P C for this reason (3111%Fill!
Owner DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y . N_
Date RECEIPT N
• WORKMAN COMPENSATION DECLARATION FSS,PER TRAP SCIIOOI,TAX Y_ N_
❑l hereby affirm that I have a artlficate of consent to self-insure,or a RECEIPT— p
3800,
LLab
380CJ E(Workers'Compewatlonlruunnreoracertlfhd ropythemof(Sec. , GAS FA SYSIFM 11NC40U7LCI5 PAI FY N
Lab
I'a11ry p GAS FA.SYSTEM-OVER 4(FA) RECI]I'I'X
Cra���______m nnnCny - BUILDING D IVIS ION FI BS
�Certifled copy is hereby furnished. GREASEQNDUSTRLi WASTE INTERCEPTOR PLANCHECK FEE
,a 'red copy he hied with tM city inspection
division.
CERTIFICATE OF EXEMPFION FROM WORKERS' GRFASE'IRAP PAID
.
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Thos section need not M completed If the permit V(irons hundred dollars
(f100)orlessJ WATER HEATER W/VENT/ELECTR C3 ENERGY FEE Y N
all am emplhat oy
anperformance
person
an say mework so as to cern eesubjecrmit 1.issued, - Z. d —
,I shale not employ any person In any California. so u to become subject to the WATER SYSELM/TREATING
Worlicant ompensation laws of mla.Date PAID '
O Z AppNOTICE NEW RESIDENTIAL PLMB. SQ,FI'. Date Recei t#
Z O NOTlCETO esubje Atothe orkeralCompleing Ctton pr vis Exe of the
,you -
F Code,shoulyou
forth it the Workers'Compmaations orchis permit s Lab he TOTAL: _
N Code,you must(odhwlth comply with each provisions or this permitshallM
'cc LA deemad revoked.' � BU[LnINC ITE .
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
f1' I hereby affirm that there V acomtructlon leadlegagenry for the perforce, l` ELECTRIC FEE
7 Z an of the work for which this permit b issued(Sec.3097,Civ.C.I TOTAL: la('�
U O cnder'gName PLUMBING FEE a D
LL•.F Landers Address QTY. MECHANICAL'PERMIT;;. l'.FEE, MECHANICAL FEE
O O . I certifythat l have mad thisapplleationand pate that theaboveinformation
Isco ect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
> ,C relating to building construction,and hereby authorise representatives oflhb
N y" city to enter upon the above-mentioned property fdInspection pection purposes. ALTER OR ADD TO MECLL
? (We)'agren to save,Indenmity an d keep harmless the City of Cupertino Date RUCCIPt#
V agaliet llablliks,}rdgmenb,coateand open mayln anywaya true AIR HANDLING UNIT flU 10,000 CFM) SUBTOTAL:
agairatvid Citynsryuena if the grants oft sill. '
AIR HANDLING UNIT(OVER 10,CM CFM) CONSTRUCTION TAX
Sigmture of AFElicant
/C. Dahl I I EXHAUST HOOD CW/DUCT) CONSTRUCTION TAX PAID:
HAZAR1 MATERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNTT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date - Receipt#
I lealth andSafely Code Section 25532(n)? HEA TING UNIT(OVP.R 100,000 BTU) '_TOTAL: I
C3Yes ri No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSU QATE
which emit hazardous air contaminants as defined by the Bay Area Air - n��
. Q+ lity Ma nagement District? - BOILER-COMP OR 100,000 BTU) 1 R C, /,
4MvaYea readtheh.9usmaterialsrcquircerentsunderCh.pter6.95of BOILER-COME(OVER100,WOBM Yr
the California Health&Safety Code,Sections 25505,25533 and 75534. I p;
understand that lithe building does not mrrently have a tenant,that it is my NEW RESIDENTIAL MECI1. StLEn -kr' of�itlR y
responsibilityriotim.of.Can occupant
stacftdthe requirementswhkh must be net
Prior m i,suance of a y the c u ant of p.thenq.,
Owner or authorized agent Date - �}.JyJV�1A-see
ISSUED BY:
OFFICE COPY