21846 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 8 1 q Q /�17 PERMITNO.
Building Addme: L 1 (i3 L o L1� �{Y '
W { 21846
Own
eN More:
CITY OF CUPERTINO-BUILDING DIVISION
contract .N Q m. APPLICATION if PERMIT A
x.Js tett/Fiyylpeer: Lie.No: BUILDINGELF MCAL-MUMBWG-MFLFIANICAL CATEGORY CONTRt 1 (_
F•(1( QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO v[
BLDG ELECY PLUMB M�li
Address: PERMITISSUANCE '�/a_ ❑ -
LICENSED CONTRACTOR'S DECLARATION L —
Ihereby affirm that l am licensed under provisions of Chapter 9(commenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwitlicc..h5ed un force of Dlvfect. fthe Buslnessand Pro/ntlonsCode,and my - �(.-�. S� �_ \
license is In full f0mand effect. PANELS I t ))
License Class Lic.p
Dale Contrador LIP TQ 200 AMPS
ARCH ITEC7PS DECLARATION X11-I OOO AMPS
m l understand my plana shall be used as public recrnds. OVER 1030 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
.U6 Licensed Professional SIGNS ELECTRICAL ♦ ' b wZP
�Q\ CC
.<� OWNER-BUILDER DECLARATION SPECIALCIiCUIT/M15C
L., z Iherebyafflrrnthat l am exempt from the Cmurador's License Law for the
8)o F Q following manon,(Section 7MI5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
F
2.cpcp��W'ai a ntywhichrequlmaperrNttowmtmcd, tegUpmve,demollah,ormpalr
asanynmdure prbrto ltslssuance,a(w requbeathe applicant(or each permit to
❑❑ ]OWER DEVICES
-. file a alto#statement that he is Bcenssd pursuant to the proof the
Contractor.License law(Chapter 9(mmrrnMg 7000)with Section 7lXq)of Divi. SWIMKNG POOL ELECTRICVALUATION
O alon 3 of the Business and Professions Code)mthat he Is exempt therefromand
YI S the basis for the alleged exemption. Any violation of Section 78715 by an OUTLET SWITCHESFIXTURES l L3 (�
`ur16Oi applicant fora permit subjects the applicant to a civil penalty of net more than l
N five hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sole
7a compensation,wllldothe work andthe structure lsnm Intended or offered for
O
sale(Sec.7044,Business and Profea•lora Code:The Contractors License Law�3$ don not apply torn owner ofproughhis wnem•oyees,povidedthatacd - _QC C. ROUI RIS.UNITS
Wes not appyuch to an owner or through wo Wilds or Imprmsthereon,and (VC"
Improvements are not Intended proffered forsale.If,however,thebullding or TOTAL:
Improvement esold within oneyearofcompletion,the owner-bunderwill have
t rden of proving that he did not build or improve for purpose ofeale.). QTY. PLUMBING PERMIT FEE, FI.OD I APN
LI,as owner of the property,am exclusively=trading with licensed pFRMTf ISSUANCE C.0 511
contractors to constmd the project(Sec.70K Business and Professions Code:
The Contractors License Law does net apply to an owner a property who ALTER-DRAW&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such p(oje with a FEE SUMMARY
co�RTador(s)licensed pursuant to the Contractor's License Law. BAIX FIAWI'ROTECT.DEVICE
L�1 am exempt under Sec B&P C for this m..
OUTSIDE FI ES
DRAINSFIOORRODF,ARLA,COND. ANII'ARY Y_ N
Owner Date �\ra�' RECEIPT#
WOR(OMAN COMPENSATION DECLARATION .NRES.PER.�P W SCITOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT N
comficataCJ S SYSTFAT
m WmkerYComperaatlon Insurance or a omifled re
copytheof tire.
3800,Lab GAEA. WCET
40UTLS PARK FEE Y_ N_
RECEIPT N
Policy N GAS EA.SYSTEM-0VFR d(FA) BUI LDINC DI V ISI ON FEES
Com any
citified copy Is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy Is filed with the city inspection division.
1C3 (
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID ��( +�• s.s�Q
COMPENSATION INSURANCE SEWER-SANTTARY-STORM RA 200FT Date RCeel ted (.7 .10
(Thlaxctlon need not be completed lithe permit ls for oda hundred delta.
($1M)orless.) WATER HEATER w/VFM/ELGCTR .� ENERGY FEE Y_ N
co _
I codify that in the performance of the work forwhlch this permit is Issued,
I shall not employ any person m any manner so as to become subject to the WATERSY51EM/TREATING
Workers Compensation Laws of California.Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQYT Date Recei t#
O NOTICE TO APPLICANT:$aXer making this Certificate of Exemption,you
HW should bemnr aubjrd to the Workers Campensation pmubionsof the Labor TOTAL:
Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING FEE
deemed revoked. \
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE C,O
I hereby affirmthat there isa comtrudion lending agency for the perform- ELECTRIC FEE
Z ance of the work for which thin permit is Issued(Sec.3097,Civ.C.) TOTAL: a(•�
(� O Lenders Name PLUMBING FEE Oa
LL H Lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l cedifythat l have read thbappliationand statethattheaWw information
d la coded.I uScdw complywith all dtyand countyordinancesand state law, PERMIT ISSUANCE FEES PAID:
r relating to building romlrudiogand hereby authorize representatives ofthis
F Zcity to enter upon the above-mentioned pmN"for Inspection purposes. ALTERORADDTOMECH.
_ o me msave,Indemnify an d keep harmless the City of Cupertino Date RCCCI t#
against slab P go"' xpense,whichmayinanywayaceme AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
a aunts dCit In u enc f e stmf,.fthIxpernll
AIR HANDLING UNIT(OVER 10,000CM)
of est/ o -91 CONSTRUCTION TAX
' dor r �e EXHAUST HOOD CONSTRUCTION TAX PAID:
gwturc o
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicaut or future building cocupant store or handle hazardous HEATING UNIT(TO IDOp00 BTU) DateRCCCI t#
material as defined by the Cupertino Munidpal Coda Chapter 9.IZ,and the - --�
lialth and Safety Cede Section 2S'a32(a)? HEATING UNIT(OVER 100,1100 BTU) TOTAL: `
Yn r]No
Will the applicant or(atom building acevpant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hara dous air contaminants as defined by the Bay Area Air
Quality Management District? BOILFR-COMP(3HP OR 100,DW BTU)
4I 1
Y. No
havemadthe hazardwsmaterials requlrementaunderChapter6.95of BOIER-COMP(OVER 100,000M)
the Califomia Health&Safety Code,Sections 25505,25533 and 25534.1
understa nd that if thebulldingdoes nm currently have atenant,that it Is my NEW RESIDENTIAL MECFI. SQ.FT.
rnpomlbility to notify the occupant of the requirerrcnts which must be met n s�
prior to Issuance of a Certificate of Occupancy. Z 6 A! .0y
Yl,
Owner r authodred agent Date 1Sq( p t vsLJ`�
TOTAL: J —'
OFFICE COPY