21303 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I PERMIT NO.
Building Address: ` ` {�t�
O [23 Nr WCTLF- Bim. )- 21303
one: A A A
�♦am �'- ` CITY OF CUPERTINO-BUILDING DIVISION 'O—�nn�
Coral ors Name: Lic.No: APPLICATION /PERMIT D_`�
2 O B LDINGELECTR CAL UMBINGMEC}ANgCpL CATEGORY CONTROL N
eluted glneer. L1c.No:
{� QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
S)GrAZA CI
Addrcs: v PFIMTISSUANCE �� ❑ ❑ ❑
LICENSED CONTRA OR'S DECLARATION
I hereby affUm that l am Bernard under provislonsof Chapter 9(wmmenc APPLIANCES-RESIDENTIAL JOB DESCRBTION
ingwitho �]0(0)ofDivlson3offl eBushesssand PrefessionsCode,and m
Been. a` .rc `fdLi1 ��
PANELS
LlmnseChs .# q
Date Contractor
ARCHITECT'S DECLARATION 201-1000AMPS
ne ]understand myplamshallbe used mpublicrecordn. OVERIODOAMPS SQ.FT.FLOOR AREA $/9Q.FT.
HoLicensed Professional � SIGNSELECTRICA1 �qe�
O
6 c0. OWNER-BUILDER DECLARATION t
SPECIAL CIItCu1T/ TSC
I lumbyafOrm that am exempt from the Contractors License Law for the
0Z. following reason(Sed1on 7031 S,Business and Pmfeulons Code:Any dry or
t9+ countywhichrequiresapem tWmmtmMalter,Impmvgdemo h,orrepalr T�P.METCROAI'OL NST
�`1S ,'ti anystrudure pdortolts Issuance,alsorequlres theappliant forsuch permit to PDWFRD t
K U file a signed statement that M is Ilrensed pursuant to the provisions of the
Owl Contractors License Law(Chapter9(commencing with Section 7000)of Divi- SWRAIAIN6 C VALUATION
m
O an.3edtheBusinessand PrefesslonsCode)orthat he hexem therefeemand
5 the basis for the alleged exemption. Any violation of Sion 7031S by anyOUTLETSSW[ FI
c. t t
applicant for a peimit subjects the applicant to a civil penalty a not more than
O five hundred dollars(x500).
�'4..' ❑1,as owner of the property,or my employees with wages as their sole NEW RESId LEL SQ STORIES TYPE CONSTRUCTION
�7Q compenaatlon,will do the work.and thestructure h not intended or offered for
D
sole(Sec.7004,Business and Professions Code:The Contractors License Taw \
EIS$ does not apply to an owner of property who Wilds or improves thereon and I OCGGROUP RES.UNITS
who daesauch work hmeel(orthrough his owo employees,provided that such
Improvements are not Intended oroffered foreale.If,however,thebullding or TOTAL:
improvement b sold within one yea r ofcompletion,the owner-W Bdarwlll have
tlakurden of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODTONE APN
u L as owner of the property,am exclusively contracting with Ilansed H ISSUANCE
contractors to construct the project(See.70K Business and Profeslons Code:
The Contractor's License Law does not apply to an owner of property who FA
ALTER-DRAIN k VENT-WATER( )
Wilds or Improves themon, and who contracts for such p(ojeds with a FEE SUMMARY
enactora,licensed Pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
LJI am exempt under Sce. B k P C for this re
m
OUYSI DE FEES
Owner Date an DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y_ N_
.
RECEBTY
WORKMAN COMPENSATION DECLARATION
F11 hereby affirm that I have a comfit to of consent to selfA s m'or FO(TURES PER TRAP SGgOOL 7A% Y N
mNficom of WmIr Compensation Insurance a a rertffied copy themf(Sec. RECEO'rN
3800,Tab C.) GAS EA.SYSTEM-1 NCAO11TLETS PARK FEE Y_ N_
RE=N
L' p' GAS EA.SYST M-OVER 4(EA)
ComECany BUILDING DIVISION Fr.ES
�ertlRed copy h hereby furnished. CREASE/NDUSIRL WA5TE INTERCEPTOR PLANCHECKFEE
❑Certified copy Is filed with the city impection division.
CERTIFICATE OF FXEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-sAMTARY-SIDRM TA.2001717.
Date RCCeI 1#
RNsseetian need not be completed lithe permit la forone hundred dollars
($IW)or les.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance ofthe work for which this permit is Issued,
I shall nm employ any person In any manner eo as to become subjectto the WATER SYSTEM/IREATING
Workers' ns
Compeation laws of California.Date PAID
O Z NOTICE NEW RESIDENTIAL EMS. SQ.FT. Date Remi t#
Z O NOTICETOAPPLICAM:R,after making rs'Com Compensation
is Exemption,you
shwld Wcome subjm to the Worked'Compensation provhlons of the Labor TOTAL:
CCN Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING '-E
W > deemed revoked.
1 o CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there baconstmdlon lendingagency forthe perform TOTAL: ELECTRIC FEE
D Z mce.ithework fmv,hich this permit Is Issued(Sec.3097,C1v.C.)
(� O lenders Name PLUMBING FEE
r Lenders Address QTY. MECHANICAL PERMIT FEE
OW IcedifythatlluvemadthhappBcaHonandslatethattheabovelnformation MECHANICAL FEE
4 iscormd.7 agreetecomplywith all dtyand countyordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. N relating tobullding construction,and hereby authomiza representatives ofthis
F Z city to enter upon the abovo-rrcntioned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(Wc)agree to save,Ind mibr an d keep harMc he City of Cupertino O ri mart ms rad ex n hma roan cerue AIR HANDLING UNIT 10,000 CFM)
againstllabl etoN g x y ywaya SUBTOTAL:
a aims Bald CityN coney ria midge fish-pemdt.
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
O
rcof phant ontra t f1 Da IXliAusT HOOD(w/D1KT) CONSTRUCTION TAX PAID:
HAZARDOUS RIALS ISCLO RIE
Willth ppBcantorfuwmbuildingocmpamstomorhandleha ous HFATINGUMT(TO100,070BTln Date Rmef t#
as defined by the Cupertino Municipal Code,Chapter 9AZ and the
health and Safety Code Sedion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: 2AI(00
F-1YesN No
Will the applicant or luture Wilding occupant use equipment or device VENTILATION FAN(SINGLE RESID) RYNCEDATE
which emit haaardom air contaMmnts as deRrmd by the Bay Area Air
Quality Management District? MOILER-COMP QHPOR 10,0(0 BTU) 1 X990
• 4un C%ai 1
haveve azynsread the hmteriab requlrcmenb underChapter G95 as BOILER-COMP(OVIRIW,000 BTU)
the ersta nd h}health A Safety Code,Sections 25505,25533 and 75537.I as.__�,JeaM
ueCalif California
at Hlathe building does red cun 25505,25533ntly have a and,that25534 it is my NEW RESIDENTIAL MGCH. SQ.Ff
rmpomibility to notify the oaupant of the requiroments which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorlud agent Date TOTAL: ISSUED BY.
OFFICE COPY