21101 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
tlulldin Project Identification 0 a PERMITNO.
Building Addevas:
o L a vLT� o l- CaEv) 21101
nere .me: nn<:
1pfbA CITYOFCUPERTINO-BUILDING DIVISION
ntrdona Na Lice.No:,
' APPLICATION /PERMIT
L &M BUILDING-ELECTRICALPLUMBLNG.MECIIANTCAL CATEGORY CONTROLN
A act/Ggjneee, /etc.No:
` n G l�0 CITY ELECTRIC PERMIT17,
FENE��s� BUILDING PERMIT INFO
Add. PFRMITISSUANCE 1 t`v
LICENSED CONTR under provisions
RATION
Ihth Sb on7OOOffunn allam Bccnsed 3ofthe uMmvLand DlChapter nslons9de,and c APPLIANCESRESIDENTIAL JOB DESCRIaION
' IngwlthSeMon7000)afDlWalon3ofthegutlnemand PmfneloneCode,andrm
Icense is lnfuB dA(M PANELS S:FDWLa
Icense Com Llc.tl - Y-�LA/
to Contractor
ARCHITECTS DECLARATION 701-1000 AMPS
q�q�vv reOQ Iunderstxrd my plane shall W used m public nmrds. OVERIODOAMPS SQ.Fr.FLOOR
,A&A
$/SQ'Fr.
E d Professional SIGNSELDCTRICAL
6 OWNER-BUILDER DECLARATION 7+s�1.-/ 4 V I
I License7�. (2
<
rn SPECIAL CIRCUIT '' rLNy'� Y
z 4 owing rafgrmthatlam31S,Business
from the dPrefictsions cense law fortheh< K46e GGI IS
foilowingichmgiroaprn1tto Bme candy, fpmionee=lCode;Any dtyor
F �" ceuntywhlrh rcquiresa permit toronetmct,alter,lmprove,d<rrol4h,orrepalr 'IFAIP.METQ40 I'OL
anystm=mpeDrtoite smance,alsorequlrestheapphcantforsuchpermltto POWER DEVICES
file a signed statement that In,411censed pursuant to the provisions of the
3wy Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELEC1tdG �LEBTFION
BOJ clon3o(the Bustneesend l'rofemloneCode)orthet he4exempttherefmmand - //��t
a.•,z77 the basis for the alleged exemption. Any violation of Section 7001.5 by any OL17LUISSWITCHES-FIX7URFS I Q Com! L
O applicant for a permit subjects the applicant to a civil penalty of net more thany d Ctl.9�--
llve hundredowner of the 00), NEW RESIDENTIAL ELPGTR SQ.FT. STORIES TYPE CONSTRICTION
�n ❑Lae owner 1 the property,or my employees with wages r thele w4
compensation,wRldothe work and the m,Code: 4 not Intended L offered for
O dole(Sot 7014,to ainowandf property
Code:The Cimproves ves I hereinlm.law t
�$ does doeot s
suclyman owner orthmug ywho nempuilds orlmproovide noryand OCC.GROUP RES.UMTS
who docssuchwork himself orthraugh his ownemployees,provitledthat such
Improvements are not Intended oroffered forule.If,however lhebuildleg or 5q LCq TOTAL: LIT
ireprovemeet4soldwithin oneyearofcompldlon,theowner-builderwill have
tll,Iturden of proving that he did not build or Improve for purpose ofule, QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to conetmd the project(Set 7074,Business and Profemloru Code: y�
The Contractor's License Law don net apply to an owner M property who ALTER-DRAIN VENT-W
Wilds or Improves thereon,and who contacts for such Projects with a r• FEE SUMMARY
cq1RTactorta)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVI E
u I am exempt under Sec B&P C for this season —
DRAINS.FLOORR F,AREA,CO ARY Y N
Owner
Data RECEIPT N
WORKMAN COMPENSATION DECLARATION • s SCHOOL TAX Y N
❑I hereby affirm that I have•certificate of consent to self-Insure,or a FIXTUREBPER L ) RECEO T N
3B00,lab C.)
certifiote DfWorkers'Compematlonlruunnmoramdiffedropytheno!(Set GAS EA gT. C. OUTLETS PARK FEE Y N
PcdiryN GAS FA.SYSTkT1-OVER (EA) RIGFRafp
Com any BUILDING DIVISION FEE
[PCertlied copy 4 hereby furnished.
❑Certified copy b filed with the city Inspection division. G /INDUSIRL WASTE INET R PLANCHECK FEE
CERTIFICATE OF MEMPTION FROM WORKERS' GREASETRM PAID rr
COMPENSATION INSURANCE R. Date Recei (#
(rhissection need not W completed if the permit Is forom hundred dollars �---
(f100artl.m.) WAT H ER /vFN'I'/EL7:CTR ENERGYFEE Y N
Icenot mplohat in the person In of th<wok W"toforwhichee permit is 4ot
I shall not employ any person In any runner at m to.some subject tot WATERSYSTEM/TREATING
Workeri Compenutlon Iowa o(GB(ornia.Date PAID
O Z Applicant ESI AL I'LMB. Date Recel t#
Z O NOTICE TO APPLICANT.It,efter making this Certificate of Exemption,you
Hshould become subject to the Workers''Compemation provisions oflhe Labor T TAG:
CC
0 Code,you must forthwith comply with such provolone or this permit shall be G
deemed revoked.
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby aft hat then 4 a curutmetion lending agency forth.perforn- dn
ELECTRIC FEE �.
Z anceof Ihcworkforwhi,h this permit is tssued(Sec.3097,Civ.C.) '(21 TOTAL:
V O Lender.No
PLUMBING FE
LL H Lcnder.Addreea QTY. MECHANICAL PERMIT FEE MECHAMCAL
OW IcertlfythaH have readth4appllcatlDnand elate thattheabovelnformunumt �rrAxa _
4 iscorred.I agree to comply with all chyand countyordlnancesand state laws PERMIT ISSUANCE Zt s.lJ PEES PAID:
} N relating to building construction,and hereby authotre representative.ofth4
Z citytoenteruponthe a bo mentioned property fort etion purposes. ALTER OR ADD TO MECH. Date- ReCei (# �L
_ (Wc)agree to neve =.n;and sp hay he City of Cupertino
ago Wt l4bil s,' rib,costsan xpcnse Ieh may In anywayaccm. AIRHANDLINGUNrr(rO1Q000CphU S TOTAL'
agaWtu ronsequenceo gra gof th permit.
y� AIR HANDLING UNIT IO,000CFM) CONSTRU
,1z IF-P7
SigOIL are (Appbran o dw at EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID- NI'{
H R OUSMATERIALS DISCLOSUR E
Will the appli nI or future building occupant store or handle hazardous HEATING UNIT(T0100,OD0 BTU) a
material as deli by the Cupertino Municipal Code,Chapter 9.17,and the _ Date RCCeI
Pica lth and Safety Cad r Semon 25531(a)7 HEATING UNIT(OVER 100,00/BTU TOTAL:
❑ Yea . We
W1llthe applicant suture tau llding occupant use equipment or It evices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air coma minants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DEBTOR 100,000 BTU) G
Yrs No SSRAI®
havcrcadthehara a srnaterialsrcquimm ntsunderChapter6.95of BOILER-COMP(OVER 100,000 RTU) PR ��^�
the California Health&Safety Code,Sections 75505,25533 and 25534.1 Apr L�
understand that ifthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT 1'\
responsibility to notify the occupant of the requirements which at be met
prior to Issuance of a Certificate or Occupancy.
kcity of Cupe(`7^^
Owner or authorised agent DateDB
_ �
OFFICE COPY