21588 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proed Identification /� PERMIT NO.
Building Adds: #aP a 21588
wnere ams: - one: APPLICA 110N sUManT-AT=.
�G - Cer�rrnev 4/ _rfly--kso� CITY OF CUPERTINO-BUILDING DIVISION
ct
cnn aor's Name: 's LIc.N.: APPLICATION /PERMIT
BUILDING-ELECTRICAI.PLUMBING.MECHANICAL CATEGORY CONTROL M
Architect/Engineer. f Lk.Na;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I PLUMB
PERMATTSSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingw"th SAodon70W)of Dlvldon3 oftha Budnessand ProfesslonsCode,and m
license is In les ddlM. � PANELS �/ �a l0/ 4,W
LIcen3SCIass�Cont K�f `iW
Date YY 11 I1 C HITS or �Ay pn� -UP TO 200AMPS
ARCHITECTS DE LARAiION OVER 10AMPS
a0 O I understand my plass shallbe used u public records. DVER 1000 AMPS SQ.IT.FLOOR AREA 5/SQ.Ff.
ti d Licensed professional I SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SI'ECIALCItCIRT/MISC
L., Iherebyaffirm that Iam exempt from the Contractoes License Law for the
Z following reason.(Section 7031.5,Business and Professions Code:M d or
Ff' countywhlchrequimsapermRtonoutmd,alteglmpmve,de=ilsh,orrepair TEMP•ML'fER OR POLE INST.
anystm=mpriortaiblswancgaWmquimstheappliantforsuchpermltto POWER DEVICES
rNG fil...igned statement that he Is Bcensed pursuant to the provisions of the
SOw Contractor's License Law(Chapter9(rommenclogwithSection7000)ofDlvl-
OS , sion3ofthe Buslnessand PmfeadoneCede)mthat helsexempttherefromend SWIMMING POOL ELECTRIC VALUATION
�s
the basis for the Alleged exemption. Any violation of Section 70315 by any OIJILETSSWITCIiESFIXTURES• �a J� ar•QV
GX appllcant(ora permit subjects the applicant toss dull penalty of nor more Hup a'7 •.
five hundred dollars(SM. ', NEWRESIDENTIALELECTR
❑I,as owner of/he property,or my employees with wages as their sole �'� SI'OR1PS TYPE CONSTRUCTION
7< compensation,wfldothe work and the structure isnot Intended or offered for
O .1.(Sce.7044,Budness and Pmfeasloro Code:The Contractor's Umrue Law
$$ does not apply to an owner of property who builds or improves thereon,And OCC.CROUP RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended orof(ered forsale.If,however,thebullding or TOTAL:
Improvement lasoldwlthln oneyearofcompleliogtheowner-bullderwlll have
tliturden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively nontrading wkh licensed PERMIT ISSUANCE
contractors to consumer the project(Sec.7044,Business and Prefessieu Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT•WATER(EA)
Wilds or Improves thereon,and who enormous for such p(ojects with a
cgp[[adw(6)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sea B k P C for this reason
DRAINS FLOG ROOF, SANITARY Y N
OUTSIDEF
Owner Date R• RI'-A.COND' RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES pgg TRAP SCHOOL TAX Y N
hereby affirm that I have•mrtiflrth,of conaent to sefdnsure,ora RECEIPTNM
ceAifimteo(Workers'CompeuatlonluumnmoramAifled mpythereof(&a GAS CA.SYSTEM-1 INC.40UTLETS
3800,Lab C.) /� PARK FEE Y_ N_
Pollry#_�WC� I07p03 RECEIPT#
Com GAS EA.X�6>11 I[— BUILDING DIVISION FEE
9Certl(ied ropy tv hercbythMshed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECKFEE
�eRRled ropy V filed with the city lupectlon division. ,
CERTIFICATE OF EXEMPT ION FROM WOKKCRS' GREASE TRAP
PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORDate Reed
(This section need not W completed If the permit b(or one hundred dellare M EA 7o0FT Pt#
MMorlen') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cenify that In the pedmxbuster,oanaf the work forwhich this permit la ued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
Q Z Applicant
Z O N0710ETO APPLICANT.If,ager making this Certlficateof ExemptWn,you NEWRESIDEhMALPLMB. SQFT. Date Recei t#
Amid become sub)m to the Workers'Compeuatiun provisions of the Labor TOTAL:
� V3 Code,you=at fort hwlth comply with such provisions or this permit shall be
�j deemed revoked. U f]x
LU CONSTRUCTION cons LwDINc AGENCY _ SEISMIC FEE
I hereby affirm that there i a nouwdssu lending agency for the perform, ELECTRIC FEE
0 Z Lendne Nwork(car which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
LL O Lender's Name PLUMBING FEE
LL H Lends lAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W beret.It gr tocoeadlhbapallcit and utatyordina aboveddat laws
6 brofinet.building complywRh all ndtyandnouhorlee representatives
date laws PERMIT ISSUANCE FEES PAID:
} relat enterg to ildingup..
muWdlon,andhereby dprope tyori in rcpressnpurpos o(this
Z city WE)aree to ave,he Indemnify anit propertyfor lnspe Cit purposes. ALTER OR ADD TO MGCH.
— (We)agree to judgments,
indemnify an d keep harmless the City of Cupertino Dale Recei t#
ago Ihbllltin,pdgments,aMeandex nen which may In any wayacaue AIR HANDLING UNIT CEO 10,000 CFM) SUBTOTAL:
ag sddC mono (the ng of this perm".
//y��,/p' yy�I A AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig .wnc.f Appfranl/Cgd.ctor Date E%HAUB'T How(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheapplicantorfuturcbWlding occupant scoreorhandleh.olous HEATING UNIT(TO 100,000 SM
material as defined by the Cupertino Mun"dpa l Code,Chapter 9.17,and the Date Recei t#
Health and Safety Code_SectJ#s2S537(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes e
Will the applicant or turebul Ingoccupantuseequlpmentordevlces VENDLATION FAN(SINGLE MID) ISSUANCE DATE
which emit hamrdOu9 air, vents ae defined by the Bay Area Air
Quality Management Di 7 BOILER-COMP OHP OR 100,000 BTU)
Yes No
California
read Healthe h
a Safety
Code,Se requirements 255nb5533 and 25534.
of BORER-COMP(OVQt 100,000 BTIA
the California}fealth&Safety Cade,Sections 75505,ti533 and 75534.I
ua and that iflhebuilding does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
Iblllty on he
ocarpantof tl dmmnb which must be met
p r Issue cola Irl Occu
ner or authorized a ant Date
TOTAL: ISSUED By
OFFICE COPY