21328APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BuRdln Pruen Identification ;0`, �/'L/
Buliding d sa: - - 7 e�`� va`/
PERMITNO.
5.6
21328
ceraName: one:A
_S'X/
Lia, No.
/
CITY OF CUPERTINO�BUILDING DIVISION'
APPLICATION I PERMIT
BU)LDINGELECTRICAL-PLUMBINGMECHAMCAL
A
D-2 D
CATEGORY
CONTROL#
) ser.
ArchLk. No:
QTY ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
Address:
❑
PERMITISSUANCE!Y❑
LICENSED CONTRACTOR'S DECLARATION
I hemhya(.7000that Dimi.i 3.RunderprovlalansofenionsCode,mmenc-
In ease 1. e. full 001)of d ulelm3o(the Busineasand Pro(esslonsCode,and my
license is infull and effect. r7
Llanse Lic.#�
APPLIANCE4RESIDENTIAL
JOB DESCRIPTION
PANELS
Date Contractor 'UP
TO 2DO AMM
201-1000 AM15
ARCHITECTS D ARA ON
OVER 1000 AMPS
SQ. FT. FIj@ORAREA
$/SQ. FT.
I understand my plans shall be used an public records
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Limnos law for the
SPECIAL CIRCUIT/MLSC
TFMP.METO2ORIPOLE INST.
followingresson.(Section7031S, Businessand Professions Code: Any city or
county which requires a permit to mostmct, alter, Improve, demollsh, or repair
anystmc mprlortoltaIs ance,ahomquiastheappliantforsuchpermitto
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Lw(Chapter 9(commencing with Section 7W0) of Divi-
of the Business and Professions Code) or that he in exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit aubjectathe applicant to a civil penalty of not more than
POWER DEVICES
SWIMMING POOL ELECTRICslon3
OUTLETSSWITCHE4FIXTURFS
VALUATION
NEW RESIDENTIAL ELECTIt SQ.FT.
flue hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sok
B
TYPE CONSTRUCTION
compensation, will do the work and the structure Is"intended or offered for
.to (Sea 7094, Bushels and Professions Cade: The Contractors License Lw
data not apply to an owner of pmpeny who Wilds or Improve, thereon, and
who does such work himself ortheaugh his own employees, provided that such
OCC. GROUIa
RES UMTS
Improvements arc at Intended or.ffa.d tarsale. If, however, the buMist; or
Improvement issold within omyearofeampletlon, the ownerW Ilderwill have
TOTAL:
I rden of proving that he did not build or improve for pu rpose of oak.).
tyI, ae ..or of the property, am exclusively contracting with honied
contractor, to construct the project (Sec 7094, Bushes, and Professions Code:
QTY. PLUMBING PERMIT
FEE
PERMIT ISSUANCE
FLOOD WNE
APN
The Cudeactor'e License Lw does net apply to an owner of property who
WIIds or Improvers thereon, and who contracts for such ptojects with a
c(ector(e) licensed pursuant to the Contractor's License Law.
L� 1 am exempt under Sm B k P C for this reason
ALTER -DRAIN k VENT - WA77II2 (G)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR, ROOF, AREA, COND.
FIXTURES. PER TRAP
SANITARY Y N
RECEIPT p
Owner Date
WOR KMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to sel&insure, ora
certlfiab of Workere'C m e�paGtf o�nlneuranm9F�c�rtlt4d ropytherco(($ec.
3800,1 ois CJ �/ (rt
SCHOOLTAX Y N
RECEIPTN#
GAS EA. SYSTEM -1 INC OUTLETS
PARKITM Y N
Policy p_ (
D� ``�
Cram an r
y
f:crtl0ed py hereby tur^W ed,
Cenlfted ropy Is (lied with the city Inspection division.
p
GA&EA. SYSTEM -OVER
GREASE/INDUS71tL WASTE INTQtCEPTOR
DING DI
BUILDING DIVISION FEES
PLANCHEGIC FEE
GREASETRAP
CERTIFICATE OF IXEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
M
fThlesbn need not W completed lithe permit Is(oram hundred dollen
(St I unify
Illnot that in the person inan tmannerhe work sores to becaseesubjecrmit 1. Issued,
I shall not empty any person In any manner n ss m become subject to the
WorkersCompensation Laws of California, Date
PAID
Date Recti t#
SEWER-SANITARY-SIDRM EA 12071•
WATER HEATERW/VENT/ELEGTR
ENERGYFEE Y N
PAID
WATIR SYMIM/TREATING
Applicant
NOTICE I'O APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compematlon provisions of the Labor
Dale Recti t#
NEW RFMDENTIAL PLMB. _SQFT.
TOTAL:
Code, you most forthwith comply with such provisloru orthls permit shall be
deemed revoked.
BUILDING FEE
SEISMIC FEE ss
CONSTRUCTION LENDING AGENCY
I hereby afflrmthat there is a romtruction lending agency for the perform-
ance of the work for which this permit Is Issued (Sec. 3097, Cle. C.)
TOTAL:
-
ELECTRICFEE
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
Larder's Name
Lenders Address
I cedifythat l have read this applicailonand statethat theabove Information
Is correct. Iagree to comply with all city and county ordinance and stale laws
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby auth mice representatives of this
city to enter u Pon the above-nrxod Dad property, for impaction purposes.
(W handlesset to save, Indemnify an d keep handless the City of Cu ped Ino
ALTERORADDTOMECH.
Date Reeei [#
P
,gal tRa line, g 1 expemnwhlch mayln anywayaarus
aIf t dCi I vequonce It gra^tingotthlsp rmit
AIR HANDLING UNIT 10,000CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
Slgromrco(Applusn' o dor Dam
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or hours building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.11, and the
Iialth and Safety Cod Ion 25532k)?
❑ Yes o
Will the a pplicant tvrc building occupant use equipment or d evice,
which emit haro rdoue air contaminants as defined by the Bay Area Air
Quality Management District?
Yes�f No
4h ave readthe hu.7ou,materia requlremnsunderChapler6.95of
Dale Recti t#
HEATING UNIT (OVER I W,001 BTU)
TOTAL: Q
VENTILATION FAN (SINGLE RESID)
ISOJAN�E DA'L'E
i/bll `ice
OCT ,rxxeses
Is��u
BOILER -COMP (31 ITIOR 100,0(0 BTU)
BO LER-COMP(OV�t100,000BN)
the California l lealth k fety Code, Sections 25505,75533 and 75534.1
NEW RESIDENTIAL MSCI 1. SQ.rf,
undo d that ifthebulldingdoa of currently have a tenant, that it Is my
PH mi use fy( pa therequbemart. which most bemet
Ossa use of fcateo parry.
or author ag ate
City OF Cupertino
P
klj(�
ISSUED BY: t C
TOTAL:
OFFICE COPY