21109 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY /gyp
Building Project Identification ��'1ye PERMIT NO.
WD,
on 0-ms: „ T- % I Yp 21109
0 3 S o (�
weer. ante: D one:
`- CITY OF CUPERTINO-BUILDING DIVISION
• Conha ar'sN sAPPLICATION /PERMIT
rc I! En r. - BUfLDINGELECTRICAI.MUMBINCMECHANICAL CATEGORY CONTROL M
G
['+1 Lic.No:`i '1,(06 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:. PERh9TISSUANCE `L
LICENSED CONTRACTOR'S DECLARATION 1-1,7
I hereby affirm that lam Licensed under provisions of Chapter9(comment, APPLIANCE&RESIDENITAL JOB DESCRIPTIONIngwith Sectlon7000)0(Dlvisim3 ofthe BuNrsasandfentonsCode,and my
limes Is In f.Afq.and effect. Q�a PANELS
Limn C LION 3 rr✓� S��WL
Dat SV-4 oebaaor XVU UP TO 2DO AMM
ARCHITECTS DECLARATION 2014000 AMPS
OZ I understand my piams shall be used as public records OVER1000AMPS SQ.Fr.FLOOR AREA 9/SQ.FT.
O
oCb Limnred P1RQlaral SIGNSELECTRICAL
6 IOWNER-BUILDER DECLARATION /J L/.1111 n SPECIALCE(CUT/MISC
owing rasonm Hu[Iam xempt 313,Business
and
Professionsors ode:ense law fee the �
o qqqq following reason.(Section 70315,Buslned and Pro(ealone Code:An city or
TEMpmq, county which requires a permit to construct,after,Improve,demolish,or repair p'METI'R ORPOLE INST.
a any structure prior to its issuance,also requires the a ppllrant for uch permit to
V file a signed statement that he es licensed pursuant to the provisions of the ]OWER DEVICES
Oµ Contractor's License law(Chapter 9(commencing with Section 7000)of Dlvi-
�OS cion 3 of the Busheassnd ProfesionaCode)mthat he la exempt therefromand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTUMSWITCHESFIXTURES / Q �� r D 13
Oapphrent fora permit subjects the applicant to a civil penaltyofnet morethan U
five hundred as
rowner of he pr. NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with ended as thele offeredmi.for �'�'' STORIES TYPE CONSTRUCTION
c 1.5re,l0K Beat the workendtheewdurc Vnot Intended a License
Law
O doe net apply to an,ower ofproPmfperty
CMbuilds BTh.Cimproves heamelaw
s$ woeappiytoanowner ofproughhisonemporimprovdlhdmn,and OCC.GROUP RES.UNITS
whododeuchworkhlmsel(orthraugh Msown employees,provided that such I
Improvements are not intended oroffered forsals.If,however,thebullding or TOTAL: '
Improvement b sold within one yearofcompletion,the owner-Wfiderwill have
tl(vkurden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE N-�`„rys
contractors to construct the project(Ser.7014,Buslneas and Profesedon,Code: (< `iJ
The ContrectoYs License law does net apply to an owner of property who ALM-DRAIN kVENT-WATER(EA)
builds or improves thereon, and who contracts for such p(ofects with a
cantractor(.)licensed pursuant to the Cosmut e.Lima.Law. BACK FLOW7rROTECT.DEVICE FEE SUMMARY
LJ I am demi Met Sec B k P C for this rectors
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
. Owner OUTSIDEFEES
Date - RBCEJFT#
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
QI hereby affirm that I have o Insurance
o/consent to apythe er ora RECEIPT N
mNOab of Worken'Compersatlon lrsunnce ora certified mpythereaf 6ec. CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3500,lois Cd
Policy# RECFR'f N
Com any GAS EA E BUILDING DIVISION FEES
On
copy is hereby famished. GREASE PLANCHECK FEE
Certified copy 13 filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEWER-SAN ORM EA Lip Date Rami t# r�
(Thissedlonneed notbacompleted B the permit lsforonehundrcd dollar M\�
($100really
WATER HEATER W/VENT/ELFCTR ERGYFEE Y N
Irtlly that In the performance of the work(.,which this permit b4ucd,
I shall not employ any person In any manner u as to become ub)w to the WATER SYSTEM/TRPATMG
Workemv'Compendtlon laws of GLifarnla. Date PAID
0 Z Applicant
Z NOTICETO APPLICANT.If,after maklngthis Certificate of Exemption,you NEW RFSTDENTIAL PLMB._SQ}T. Date Rcei t#
should become sallied0the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=atfort hwilh comply with such provisions or this permitahall be t
> deemed revoked.
-BUILDING FEE
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
I herebyaf Ian that there is a construction lending agency for the perform- ELECTRIC FEE
Z ancoof the work for which this permit isisued(See 3097,Civ.C.) TOTAL: Id
U 0 ]ander+Name / PLUMBING FEE
IL N= Lances Addmd QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O WImAifythatINvemadthisappllatlonaMd tethattheaboveleformatlon •� a,sII..
Lsmreact.I agree to comply withal]cityand county otdinanmsand elate laws PERMIT ISSUANCE LNJ FEES FAIR;
} S mlatinglobuildingmmtmdidn,add Mmbyauthorinmpmntativesofthls
(— (A city to enter upon the above-mentioned propertyfor W ion ALTER OR ADDTO MECH.
Z (We)agree u, ,Indcmnl an d eeMeas the of CuIno Date Retei t#
V agairs111ablliti gments, Band nsro whahmaylnanywaya a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaire In con ce ntl of this permit
"r AIR HANDLING UNIT(OVER I0,aXCFM) !CONSTRUCTIONTAXll nt/Contractor a EXHAus r HOOD(W/DUCT) TRUCTION TAX PAID:HAZARDOUS MATERIALS DISCLOSUR o QWill the applicant orfuture building occupant atom or handle hazardous HEATING UNIT(TO 100,0D0 BTU) ate Rmai tot
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 25532(¢)? HEATING UNIT(OVER 100,000 BTU TOTAL:
❑Yes IM No s
Wllitheappllant orfuum Wilding occupant um equipment ordevicos VENTILATION PAN(SINGLE RFSID) (SSI A•�
which coot hamedous air contaminants as defined by the Bay Area Air
Quality Management Distdd7 MOILER-COMP OTR'OR 100,DM BTU p�
Yd 9❑' C JAN
haveread teeth&Soler materials reoan 2555,2553 andChapter 2S534.I of BOILFR•COMP(OVIR 1!4,000 BTU) •"��
the Call(omla Health 4 Safety Code,Sections 7550.5,21537 and 7553d.I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECHL SQ.Fr
rmporeabililyto notify theoccupzta of the requirements which most be met
prior to issuance of a Certificate of Occupancy. rQ, w "`4•"-
Owner or authorlsad agent Date ISSUEDBY: �1 OF
TOTAL:
OFFICE COPY