21043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification ��� ��� PERMIT NO.
8 Oding Add as
/� 21043
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CITY OF CUPERTINO-BUILDING DIVISION "—(-1(
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C a Lie.Na: APPLICATION /PERMIT ( [ (/
BUILDINGELFCTRICALPLUMBING-MECHANICAL CKIFISORY CONTROL,
Architect/Engineer" LIC.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add rear: PERhRTI55UhNCE ❑ ❑ ❑ N
LICENSED CONTRACTOR'S DECLARATION
u lhereby affirm that lam licensed under provisions of Chapter9(mmmrnc AI'PLIANCESREADENTIAL JOB UPSCRf1'TION
telngwlth Se ion700O)of DiHsion3ofthe Businessand Pmfesslon e,and my
=!'.
nse is in al rce fact. PANELS l �
License Cl ss IC.M ►'a�h
Dale Contractor '�
CHITECTS TIO 201-1000 AMPS
V" 2 I understand my plans ehaB be usM a public recordx OVER IOW AMPS SQ.FT.FLOOR AREA b/SQ.Fr.
O
b0 Licensed Professional SIGNS ELECTRICAL
<¢m OWNER-BUILDER DECLARATION
a6d (hereby affirm that lameaempt lrom the Cent ractor's License law for the SPECIALCIRCUIT/MLSC
70 2 y: following reason.(Section 7031.5,Business and Professions Cede:Any city or TEMP.METIX OR POLE MST.
F' county which requires a permit to Construct,alter,Improve,demolish,or repair
`3 anystmctum prior to its LssuartmaLw requires the applicant for.uch Parrett to POWER DEIrICEM
yd` file a signed statement that he Ls licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commentlng with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
30 slon3ofthethumesand ProfeesiomCode)orthat hekexem therefromand
t- SRS
applicant
beats for the alleged exemption. Any violation of Section net
re any
Y �5 OUTLETSSWITCt1FSFl%TUItFS
I� appEantfora permit the applicant dull penalty of nut more than
I•" � five hundred delkn(f.W. NEWRESIDENTIALELECTR SQ.FT. STOWS TYPE CONSTRUCTION
Z c re❑1,as owner of the property,or my employees with wages as their solesolepensation,will do the work,and the structure,Is not intended or offered for
Osale(Sec.7044,Business and Professions Code:The Contractors License Law
3$ does not apply to an owner of pmperty who Wilds or Improves t hareoq and OCC.GROUP RES.UNITS
whodoessuchwork himself orthrough hisownemplayrc,provided that such
improvements arc not intended proffered female.If,however,thebuilding or TOTAL:
improvement bsold within oneyearofcompletion,themmer-bullderwill have
tl�a,den of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mnlradas to construct the project(Sec 70K Business and Protections Code:
The Contractors License Law does not apply to an owner of property who
Wilds or Impves the,em, and who contram for such plojects with a ALTER-DRAIN VEM-WATFR(EA)
ro
etbattar(.)licensed pursuant to the Contradori License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt under Sec. B k P C for this reason SANITARY Y N
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND.
e Owner Data RECEIPT Y
WOR KMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SC11OOLTAX Y_ N_
❑1 hereby affirm that I have a certilate of consent to sell-insure,or a RECEIPT M
I cvAifiateofWmkeri Compensation Insurance ora certif4d copythtnef(Sec. GAS EA.SYSTEM-1 WCAOUILETS PARK FEE Y N_
3500,Lab CJ RECEIIPI'p
PoIIryN� GAS EA.SYSTEM-OVER BUILDING DI VI SION FEES
fv� Cam any
sY J �Certlfied copy La hereby furnlaM1ed. '� /INDUSTRL WASTE INTFRCFI'TOR PLANCHGCK FEE
Certified copy b filed with the dty rspe 1v I
CERTIFICATE OF EXEMPTION FROM WORK RS' GREASE TRAP PAID —
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.20017. Date RL'CCIl#
(Thiasection need not be completed Btha permit V forora hundred dollars
($100)orless.) WATER HEATERW/VENT/ELECTR ENERGYFEE Y_ N
I certify that In the performance of the work forwhich this permit is Issued,
I shall not employ any person m any manner so as to become subjectto the WATER SYSTEM/TREATING
Workers'Compensation Laws of Callfomia.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Retei tin
NOTICETO APPLICANT:ILaftar making this Cerfi ieste of Exemption,
Z U
HN should become subject to the Workers''Compensation provisions ofthe Labor TOTAL:
CC Cade,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W � CONSTRUCTION LENDING AGENCY SEISMIC PEE
0. lhereby affirm that there Is a constmdion lending agency for the perform TOTAL: ELECTRIC FEE
Z ante of the work for which this permit b Issued(Sce.3D97,Civ.C.)
U O Lander',Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE (- O
U Icedlfythatl have readthbappliationand statethat thealeve information FEES PAID:
0 W context.I agree to comply with all dtan
y and county onditcesand state lawn PERMIT ISSUANCE Z.VP
} U) relating to building construction,and hereby authorize representatives of this
Zcity to enter upon the above-mentioned property for impaction pu rposes. ALTERORADDTOMECH. Date RCCCIFtk
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT UO iD,l%p CFM)
against liabilities,judgments,costs a od expenses which may In anyway accrue SUBTOTAL:
aga lost said City in co acquence of grant ng Of this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date IXtIAUST HOOD(W/Dl1Cp CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappliant orfutumbullding.pantawreorhandle h.rdW, HFATINGUMT(TO 100,00OBTU) Date Reeel HI
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU TOTAL:
❑Yes MN.
Will the applicant or future building occopant use equipment or devices VENILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Ara Air
Quality Mamgcmard DisMct7 BOILER-COMP OtIPOR 100,000 BTU
J[�?hy
F�No
e ad the hazy pus matetiaLs requirements under Chapter G95 of IIOILFR-COMP(OVIiRl00,0008TU)
la Health ASI ode,Smlons 25505,25533 and 25534. 1dtlatifihebul n es notarrcntlyhave,tenantthatitbmy NEWRESIDENIALMFC}i. SQ.ITbilityto r)otityt oc nt ofthe qulreme is which=atW ce M a IRc to Om ry. /"
VRi
Owner or autM1orirN ag Dae TOTAL: 6/ ISSUEDBY: V
_
OFFICE COPY