21787 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE ALL P NT PEN ONLY
Building Project Identification � _ ^ r f �T//yJ� PERMIT NO. 17(�{�7
Building Acidness:l Q 1 N\ �� r l/0 k/ki �W�r Y 1 1 8 1
wners ares: l• one: p p
CITY OF CUPERTINO-BUILDING DIVISION ^,Zp
IE
Contrsam.Name: Lic.No: APPLICATION / PERMIT -II
BUILDINGFLECTRICALPLIT/BINGMECHANICAL CATEGORY CON190
Architect/Englnrer. Lie.No: C�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ F-1 1:1LICENSED CONTRACTOR'S DECLARATION
)hereby affirmthat)ansDivision
under p Business and
sofessioer9de,and c APPLIANCES JOB DPSCRI''HON
)nesse is In fon 700D)force of andeffect. (theguslneuand ProlesYamCodc,and my �—
liansefNIntialformand c.a. PANELS
License Class LonN
Date GHITTC`r
ARCHITECTS DECLARATION OVERI0AMI'S
0] I understand my plans shah W used as public record s. OVER]000 AMPS 1'.FLOOR AREA S/SQ.FT.
�u O
LFj Licensed Proferolowl 9GNS ELECTRICAL.
6 OWNEReBUILDER DECLARATION SPECLILCIRCUIT/M15C
f„ owing d@mehatlam31.5,Business
Contractor's License Law for he
7.0 �❑�qy following reuon.(Section 7031.5,Buslnea and Professions Code:Any sty or TEMP METER OR POLE INST.
���❑ ceuntywhlch requirma permittomnstruM alter,improve,demolish,orrepair
q1�1ar,a anystructure priorto Its Issuance,alsorequlresthe applicant forsuch permit to POWER DEVICES
S w E file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License law fCha er9(com(commencing with M the SWIr(MINC POOL ELECTRIC V ATION
the basis fo the elle e d exemption. Any)violation
of exempt therefrom and Q'
Sri the basis for the alleged eects th exemption. Any violation of Section see room
by any La
�S OUTLETSSWITCIiFSFIXTURFS '[�/�
p$ applicant fare permit subjects the applicant too civil penalty door more than J s-+/ D�a.�J
$ five hundred dollars($500). NEWRFSIDENTIALELECIR SQ.Fr. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
compensation,will dothe work and thestrnnure is not Intended or offered for
osale(Sec 70M Business and Pmfessime,Code:The Cmd.d.rs License Law
does not apply to an owner d property who builds orimprovesthereon,and OCC.GROUP RFS.UNITS
who does such work himself or through hisown employees,provided that such
Improvements am not Intended or offered for sale.If,however,the building or TOTAL:
Improvement baold within one ycuofcomplertion,the owner4Wilderwfll have
tks-j�arelen of proving that he did not bulla or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOODZONE APN
"L as owner of the property,am exclusively centraciing with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)Wilds or Improves theseun,and who contracts for such projects with a
.04actor(s)licensed pursuant to the Contractor's Ltcense Law. BACKFlAW PROTECT.DEVICE FEE SUMMARY
L j I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FD(TURES PER.TRAP SCHOOL'TA% Y_ N
F-11 hereby affirm that I have a certificate,of consent to self-loam,ora RECEIPT N
certificate ofWorken'Compensation Insurance ora mni(Id copy thereof(Sec.
MWI Lab CJ GAS EA.SYSTEM-1 WG40IT1'I,ETS PARK FI7: Y N
—
Policy N RDC®PT N
Cam any GAS'EA.SYSfETM-OVER4(EM BUILDING DIVISION FEES
ffCertlfted copy b hereby furnished. GREASE/INDUML WASTE INTERCEPTOR PLANCI-JECKFEE
❑Certified copy is filed with the city inspection division. -�_L��//�]��s�L.NnnA 1! 1
CERTIFICATE OF EKEM PTION FROM WOR K ERS' GREASE TRAP PAID ✓�/ L�bl�
COMPENSATION INSURANCE SEWER.SANITARY-SroaM EA 200FT Date 11 1` Recti t#
(Thissealon need nm W completed Bthe permit is forces hundred dollars
($1 W)or lev.I WATER HEATER W/VENT/ELECTR ENERGYFEE Y— N—
I cenifythat in the performance of the weak forwhich this permit is bad,
I shall not employ an/person In any manner so as to become abject to the WATER SYSIPM/TREATING PAID
Workar%Compensatton Laws,(California Date
O Z Applicant NEWRESIDEN'ITALPLMB. SQ.FI'. Date Recti t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subjer to the Workers'Comnsbra
pertioe previsof the Labor TOTAL:
N
Code,you=at fort hwith comply with such provisions or this permit Asti be BUILDING FE t
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 'NN'g2l4
d eofth workforwhherebamnstmnssuion lending 0 Ci .C.)cy perform- TOTAL: ELECTRIC FEE
'3 Z ante of the workfor which thls permitIsIsaed(See.3097,Civ.CJ
()'0, Tenders Name PLUMBING FEE
LL F Teeders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I unity thatl have read thbapplfcationad statethattheabove Information
O W Ismrnect.Iagreetocomplywithall cityandcountyordlnancesdstate laws PERMIT ISSUANCE FEES PAID:
r IL relating to building construction,and hereby authorize representatives of this
I.— N city to enter upon the aWvo-mentloned property for inspection purposes. ALTER OR AUDIO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Rceeipt#
U against liabilities,ydgments,cmtsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,(X0 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDING[WTf(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DUC'U CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wiiltheapplica est or future building ore pant store or ha relic handous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Hralth and Safety Cdr Section 75533(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes r]No "g
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) 1$$IU �WWjWATE
which emit hazardous air contaminants as defind by the Bay Area A4
District?y M
Quality DBOILER-COMP PNP OR 100,000 BTU)
q yes Mica (JAR �2X991
have read the hazy us materials requirements under Chapter 6.93 of BOILER-COMP(OVER 100,000 BN)
the California Health k Safety Code,Sections 75505,75533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which rust be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED g
�-t
OFFICE COPY