21125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY PL49 1T
Buildln Project Identification PERMITNO.
°;:od3" D P z Cm 21125'
wners ante: one:
Q CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
13a&_ �0�-`
_o
BUILDINGELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL
Lic.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addnse: PERMITISSUANCE ICO
LICENSED CONTRACTOR'S DECLARATION LE] L[f
Ihereby affirm that 1.license under provtslomof Chapter9(commen APPLIANCESRESIDENIIAL JOB DESCRIPTION - -
ingwithS°cHon 7OW)of DiAslon3ofthe BuslnemandlPgfeRlansCode,and my
L Rlsin fu andefreC. 751,5 JLC rANFYS
Daten CI LIc.NQtl ! .,.. �.,,�,5
Date ContractorT JP TO 2DO AMM
ARCHITECT'S DECLARATION IDI-1000AMPS
as Zp ]undemtand my planahallbeused as public records. OVER'WDIs, SQ.Fr.FLOOR AREA $/SQ.Fr.
d6Lu Llcense Profenlovl SIGNS ELEC AL 'Z f� /�T
6N OWNER-BUILDER DECLARATION SPFCIALCIRC T 7/y.3 ,Yy1 'j
2 s,�. (hereby arfirmthet l am exempt from the Contractors License Law for the I I/ ll
❑ following reason.(Section 70)15,Busmen,and Professions Code:Any city or b
,. county which requires a permit to construct,alter,Improve,demolish,or repair IE.iP.METERORPOLE INS(.
any struchrm prior to its Issuance,also requires the applanHanuch permo to POWER DAIL I)
O Ole a signed statement that he Is licensed ���
(� gra pursuant to the provisions f the
dosContractor's License Law(Chapter 9(mmmentlng with Sedion 7000)of DWI-
Mona oftheffusinesnand Pmfeeslons Code)orthal he is exempt therefromand SWIMMING POOL ELECTRICVALUATION
<�
the bandfor the alleged jeexemption.p Anyviolationtolacivi or Section nor room than
OUTLETSSWITCHES-RKTURES / Y `/
appllandred donors IISM.subjects the applicanitoadvll penalty of nor more flan UUU J VVV ✓✓✓ can---///
OA flue hundreddollarshepr.
� �1,as owner of the property,or my employees with wages as their Rle NEW RESIDENTIAL ELFC7R_SQ.Fr. Stt)WIS TYPE CONSTRUCTION
compensation,will d o the work and the structure Is not Intended or offered for
0 safe ISM 70K Business and Pmf.kms Code:The Contractors License Law t
$ does not apply to an owner of property who Wilde or Improves thereon,and
6 whodaeseuchworkhm iforthr°ughhdownemployreo,providedthatwch OCC.CROUP RFS.UNITS
improvemend are not Intended oroffered(°reale.If,however,the W ilding or TOTAL:
improvement esold withinoneyearofcompletion,the owner-builderwill have
H),kurden of proving that he did not baud or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FIpO ZONNE APN
LI I,as owner of the property,em exclusively rontrating wllh u—ned PERMIT ISSUANCE CO
to constrott the pro)ed(Sec.7044,Busmen and PrOmimu Code:
TM Contactoh Ll...Law do.not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves,thereon,and who corc
mucts for such project with a
�gRt(�dor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Set g k P C for this masonQIJTq1nF FEES
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORK MAN COMPENSATION DECLARATION❑ FIXTURES PER TRAP SCHOOLTAX Y N I hereby affirm that I have a txrtl0ate of consent to RI(-Insure,or RFCErr
3800,ale of Workers'CompensaHonlnsunnremaartlfle copythemot(&c. GAS Fit.SYSTM.1 ING4 OUTLETS
3EOQ Lab Cd PARK FEE Y N_
Policy N RECEIPT p
Com an GAS EA.SYSTEM-OVER4(EA)
Y BUILDING DIVISION FEES
codified copy Is hereby filed
the city GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�CertNe copy Is filed with the tlty inspection division.
CERTIFICATE OF E)(CMPTION FROM WORKERS' GREASETRAP PAID ..�
COMPENSATION INSURANCE SLWER SANITARY
(rhlssection need not becompleted lithe permit Isforone hundreddollan RIDRM EA.20OFT. Date RCCCi lot ' -]f W
a1I mKilWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Irertl(ythythet In the performance of the work(orwhlcF lee permit is Issued, —
1 shall not employ an/person in any nunncr eo n to become subject to the WATER SYSTEM/TREATING
Workems'Compematlon Gwsof Gllfomd.Date PAID
O Z Applicant
Date Recei 1>I
Z 0 NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr.
Hshould becomesubject to the Workers'Compensation provision of the Labor TOTAL:
M N Code,you moat forthwith comply with such provisions or this perndt shall be
j deeed revoked.
UI G FEE
a mG CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there Is a coratrudion lending agency forthe perform. 4 ELECTRIC FEE
M O ante of the work for which this permit Is Issued(Sec.3097,Civ.CO TOTAL: 0 s fl
U _ Lenders Name PLUMBING FEE Q Q
LL H Lenders Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 6 Q
O W lartlfythallhavereadthdappocut.nandstamthdthogmmintornutian s� ,p
doo ma.Iagree to comply with al dlyand county ordinances and gate laws PERMIT ISSUANCE (4l(d FEES PAID:
} 0- relating to building mntructlon,and herebyauthodoa mpresentativesofthis
I— Z citytoenterupon the abovcmenliooed property for Inspection purposes. ALTERORADDTOMECH. Date RCCBI [N
(We)agree to sa emnlfy dl- rmlen the City of Cupertino
agairst Uabiities' mente,co rad ex ew hmay In an ways a AIR HANDLING UNIT 10,000 CFM) SUBTOTAL•
agalat nconsequ orth lin thbpermlt.
AIRHANDLINGUNrT(OVER tO,OW CFM) CONSTRUCTION TAX
rcof App ontrador ate EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
A2ARDOUS MATERIALS DISC1<SUd ¢ 1
WllltheapplcanI ortuture building occupant store or handle haeardous HEATING UNIT(TO 101,0DO BTU) Date Recei ted / O�sy
material act defined by the Cupertino Munldpal Code Chapter 9.1$,and the -
Iiealh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
QYea M No
Wllltheappllant or future Wllding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSfATE
which emit harardous air contaminants as define by the Bay Area Air
Quality Management District? BOILER-COMP(3FR'OR 100,000 BTU) FEB
4 Yes No
havcread earthhe ar et m ode,l.Se tioW25505, 5533underand
6.95 of BOR.E2COMP(OV[R 100,000 BTU)
the Glifornla health&L Safety Cade,Sections 75505,25533 and 75536, 1
understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT pp��jj PA
responsibility to notify the ocrupant a the requirements which moat be mot N-'1 HBQPaI�•�'O
prior to Lwuanco ofa Certificate of Ompanry. Ott PA;.�+ 0'^/,
Owner or authorlaod agent Date ISSUED BY: D`�s I`—�"""'�V
TOTAL,
OFFICE COPY