21548 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identificationec95-)
` PFR.WT NO.
Building Address: uJ +� 95-) 21548
Phone: IAL UAIL
:r i CITY OF CUPERTINO-BUILDING DIVISION
C/fnfcttyo�s$ I Y-
r'flName:
�a' APPLICATION /PERMIT ��� 140
`� �IBIIILDINGFLECTRI:AL-PLUMBING-MECHANICAL
CA7HCORY CONTROL.#
Architect/Engineer. -s-�-a-�i Lb,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naa.aa: PERMwnssUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihembyaffirm that l am licensed under provisions of Chapter9(commenc APPUANCFARFSIDENTIAL ]OB DESCRIPTION
'ngwlth Sed1on7000Iof DiWgm3ofthe Budnessand Pmfe maCodG and my
ifcense is in run fa • ddied' �/ PANELS Q1 a `s,,�(7
License Cla G Lic.M�Z6 ZZx { `�'\\t37
DatS/��Contrador 7. -2; ,� UP TO 200 AM
-
ARCHITECTSDECLARATION 201-100AMPS
as 07 I understand my plans stun be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
X Fj Licensed Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIALCIRCUITIM19C
L., Ihercbyafflrm that lam exempt from the Contractor's License Law for the
7 G following reason.(Section 701.5,Business and Professions Code:Any city or
O TEMP.METER OR POLE INST.
1 49, cauntywhich requbesa permitt.constmet,ilter,bnprove,demolish,arrepilr
YY�I anystmdurepr toil.) ance,aborequirestheappbmntlorsuchpermitto POWER DEVICES
KJ file a signed statement that he is Licensed pursuant to the provisions of the
�3wG Contractor's License Law(Chapter 9(rommenMgwith Section 7000)ofDivi- SWI.rMINGPOOL ELECTRIC VALUATION
O alon3 ofthe Business and ProfessionsCode)orthat he la exem therefromand
il;a' the Iasis for the alleged exemption. Any violation of Section 7015 by any OUTLETSSWITCIIFSITXTURES
applicant for a permit subjects the applicant to a civil penalty a not morethan
a � five hundred done.($5W. NEWRESIDENTIALELECTR SQ.Fr. STORIES TYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
C�6
compensation,will do the work,and the structure is not Intended or offered for
sale(Sec.7044,Business and Professloro Code:The Contractors Lt...Law
docs ata apply to an owner of property who Wilds or Improves thereon,and OCC.CROUP RES.UNITS
who doessuchworkhlrtunn orthrwgh hisown employees,provided thatmch
improvements are not Intended oroffered forsile.If,however,thebullaing or TOTAL:
improvement issold within oneyearofcompletion,the owner-builderwill have
th rden of proving that he did not Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
L1,as owner of the property,am exclusively=trading with named PERMIT ISSUANCE .L�
romns
ntractoss to trud the project(Sec.7016,Business and Professions Code:
The Contractors Llcerae Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improve thereon, and who contracts for such piojects with a FEE SUMMARY
dInriecuir(s)Boomed pursuant to the Contractor's License Law. BACK FTOWPROTECT.DEVICE
I,J I am exempt under Sec B 4 P C for this reason 'FEES
Owner Date RAINS-FLOOR COF,ARC� SANITARY Y_ N_
• RECEIPT p
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP f s e- SCHOOLTAX Y_ N_
Of
hereby affirm that I have a cortNate of consent to self-Imre,ora O RECEIPT I
certificam.fW.rkeri Cwnpensation Insurance or a certlfed copythemof(Sec. GAS EA.SYSTEM-1 INCA O Ery PARK FEE Y N_
380,Tab C3
R1xE7I'I'M
PoliCFTC GAS EA SfQd-0VERd ) BUILDING DIVISION FEES
Com ny
�ertiOed copy Is hereby fumished. GREASQNDUSTRLXAj0AEkEpTDR PLANCHECK FEE
IQCertified ropy Is riled with the city Inspection division.
S� CERTIFICATE OF EXEMPTION FROM WORKERS' G TRApad fF i V PAID
COMPENSATION INSURANCE -gro Date Recel t#
(Thissedion need not W completed If the permit la forom hundred dolls.
(5100)otifyth / W,A 7F7i W/V TR ZaO$ ENERGYFEE Y_ N_
1 certify that N the performance or Ne work for which this permit Is lased,
I shall not employ any person in any manner so as to become abject to the %VATSY /�71FATING
Workers'C.mpensatlon laws of California. Date PAID
0 Z APpllcant NEWREA RNTIALPLMB. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you a
PN sM1wid become subject to the Worken'Compensatiw provisbns.(the Labor TOTAL:
cc C.de,ymi muatforthwith comply withsuch provld.nsorthis perndtshallbe BUILDING FEE
W D deemed revoked CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby afflrmtlut there la a construction lending agency for the perform- �1 ELECTRIC FEE
M Z aamofthe work for which this permit la isaed(Sim.3097,Civ.C.) TOTAL: Data
02 Lenders Name PLUMBING FEE 0.
IL I— Ieadcea Aad css QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icedlfythat l have read this applicationand statethattheabove information
0 W laconect.legree to comply vith.11 city and countyosdinencesand nate laws PERMITISSUANCE FEES PAID:
>. C relating tobuildingconnruRion,and hereby authorize representatives ofthis
(_ Z city to enter upon the abovo-memloned property for inspection purposes. ALTER OR ADDTO MCCH.
(We)agree to save,indemrdfy and keep harndcw the City of Cupertino Date Receipt#
0 agathal , dsic.paenseewhchmayi..
eywayaocrue AIRHANDLINGUNT(TOI0,IXp CFM) SUBTOTAL:
gmingofthspermit AR HANDLING UNIT(OVER tO,DOCFM) CONSTRUCTIONTAXboLOlA
Ignsture of ant/Contractor re FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAU RDOUS MATERIA LS tsto SUR
Willthe defined
byf flit
goicipan ode,Chapter
Zandous HEATING UNIT CFO 10,00BTU) Dale Recei !#
material as defined by the Cupertino Municipal Code Chapter 9.12,and the -
HealthendSafelyCalar�Sedi.n25532(a)i HEATING UNIT(OVER 10,00 BTU) TAL:
n Yes II No
Will the applicant orfumre building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUA TE
which emit harardous air contaminants as defined by the Bay Area Air 6 1
• Quality Management District?
OFI'OR 10,0(p BTU) la� �QQ(L
Yes QN. ww}}VV
have read the huaraims materials requirements under Chapter6.95 of BOILER-COMP(OVER 1000 BTU) //���1a�-�
the California Health k Safely Code,Sedions 25505,25533 and 25534.I
understand that lithe Wilding does not comently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.IT. ����FF55+�z.11 C{!aV'ffYt�11Mfi1
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUEDBY: uV��Y•i/� �z-
TOTAL:
OFFICE COPY