21378 (2) I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect ldentlfi<ati.n - PERMIT NO.
Budding Address:
-Ave- 21378
�1S R,laly
ere aces: one: AFFLICA LION SUBMITTALA
TE
�E66Y 5 CITY OF CUPERTINO-BUILDING DIVISION
cn raetnr'i Name: �, zee.No:'17 APPLICATION I PERMIT td'� C
1 'T 0 1 / BUILDINGELBCTRICAIPLUMBING-MECEIANICAL CATEGORY CONTROL
Ao' /Englrie Llc,No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 0� `T? PFRMITISSUANCE UD
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commare. APPLIANCESRESMENTIAL ?tIE,
ON
Ing with Section 7000)of Divlelon3 ofthe Business and Profession,Code,and my 1''�
lirense Ts in fo and effect. PANELS t''�I'� P
LlcenacChssf n-I Lic.M �'`�3 C7�� zU �^� `C't,0;'L-
Date l� (}Contractor —UPTO200A S .5" 4t7
�r�� ILCHITECI'B DECLARATION 201-IODOAMPS
�O Zp I understand my pians shall be used as public records. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQG.FT.
z(Cj Lirensed Professional SIGNS ELECTRICAL .,a4 8 o 1 tt Z O
DECLARATION
VV V
6 OWNER-BUILDER {y ^
In FnSPECIALCIRCUIT/MISC `J��t
t, rasormSectio 70312, tfromthrdPretfessimLianasLawforthe SS' ^Z5
x0..p
following myrehrequ(Section tW,Bmtmda to Professionsemle hn d or
y city TEMP METER ORPOLE INST.
countycture riorWsa issues tmconsrequiratheaprovetforsbh,urtr
5 any assigned prior that
he i,licensed
to the provisionuch s
ofto pOWpS(DEVIC�S
9 1 file a actors statement that he in(Chapter 9(cod pursuant it the poo 7000) of the
33
Contractors LiLicmes Lawwrofesslon Cods)encingorthat with sectmnherefof Divi. SWIMMING POOL ELECTRIC
slon3ofthe Business and Profe,eloru Code)orthat Mei,exempttherefromand VALUATION
N S° the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES a y <
�_yo$
applicant for a permit subjed.the applicant to a civil penalty of not more than
C Eky five hundred dollars($500). O s
�j I,as owner of the property, with wa es as their sole NEW RESIDENTIAL ELECTR SQ.FI. STOI0F5 TYPE CONSTRUCTION
•Q^fin ❑ P or dor^7B
compensation,Businessl do workfesthe ionstructure is not Intended o iofferedfor
O
Is(Sec.7044,Busmen and PMesslons Code:The Contractor'.Lirense Law
does not apply to an owner of property who builds or improves thereon,and
UNITS-
who does such work himself orthrgh his own employee,,provided that such OCC,GROUIa RES.UNRS
w
bnpmvementsamnai tendedoroffemdfwsxle.I$howeverthebuildingor TOTAL:Z3. -
improvementbwldwithinoney+earofcomple lon,theowner-huMerwillhave
I c rd�en of proving that he did not build or improve for purpose ofsals.). QTY. PLUMBING PERMIT FEEpLODDZONE APN
.
..or of the property,am exclusively contracting with licensed
cosonsemne to corutruct the project(Sec.700 Business and Prons fessioCode: PERMIT ISSUANCE , DO
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) •Ca
Wild. or Improve.thereon,and who contract for such ptojects with a
c tractor(.)Bearers pu ant to the Contrsem''•Licen.Law. FEE SUMMARY
IJI r Sec. B&P C f thb aeon BACK FLOW PROTSCT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
ne r - Date RECEIPT N
w "MAN COM ONO CLARATON p1X'1VRES PER TIiA1s SCHOOL TAX Y— N
❑ here affirm that I ha certIfL of consent to self-insure,ora .DO "^ss
¢rt cut orken Compensation Insurance w a certified copythereof(Sec. RECEIPT
38 CJ CAS F.A.SYSTEM-1 INCA OUTLETS . QQ PARK FEE Y— N—
Poiky N GAS EA.SYSTEM-OVER d(FA) RECE3PT N
Co^ nY BUILDING DIVISION FEES
�Certlfied copy b hereby Formatted.city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Cesi(ied copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA.200FT. Date Reeel t#
Qhlssectlon need not be completed If the permit b fwone hundred dollars '136 t le
($100)or1ess') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I mrtifythat in the performance of thewwk forwhich thla permit issued, —
I shall not employ any person in any manner w as to become subject to the 1 WATER SYSTEM/.LREA•I,ING ,�� pplD
Workers'Compensation Laws of California.Date
z Z Applicant .-Ply
Z 0 NOTICE TO APPLICANT;to
after Raklnm a Ctionp eof..oft eLyou NEW RESIDENTIAL PLMB. SQFT. Date Recei t# /7
H W aM1wid become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provLsmw or this permit shall he
LU j deemed revoked. BUILDING FEE sC0
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Ihembyaffirm thatthereisa construction lending agency forthe perform ELECTRIC FEE CJY1
7 Z once of the work for which thio permit^cawed(Sec.3097,C1v.C.) TOTAL: � aZ wOCf%
U O Lender'.Name PLUMBING FEE
y F Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
,, O Icertlfy that have read thisappBcution and state that the above information p a
W
isconect.l agreeto comply with all city and county ordinanceeand state laws PERMTTISSUANCE z,v/ FEES PAID:
t relating to building ronstruction,and hereby authorize representatives of this T
Z city to enter upon the above-me Zoned property for inspection purposes. ALTFRORADDTOMECIL SOD
(We)agree t rave de an d keep harmless the City of Cupertino Date ROCeT(at#
J again. n Date and expenses which may In anywayaccrus AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
as tea n co race the granting of thi.permit.
.e AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Si Appllcen Co. ctor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H ARDOUSMATERIAI.'DISCLOSURE
Iltheapptic w Future building ocevp.m.wre or handle hazardoua HEATING UNIT(TO 100,000 BTU) Date Recei t#
ma rialasdefin by the Cupertino Municipal Code,Chapter 9.12,and the
Mend Saf Code Section 25532(,)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yea No
Willth ppilcantor N.buildingo pantumequlpmentordeviws VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
h t harardous air contaminants as defined by the Bay Area Air �_y
Management District? - BOILER-COMP(3HP OR 100,000 BTU) A®
Yes II�II No
I have read the haeaid"ous materials requirements under Cha per 6.95 of BOILER.COMP(OVER 100,000 BN) n pQQ7
the California Health&Safety Code,Sections 25505,25533 and 25534.I IM3� ( 1M�i+
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirement.which must be met
prior to issuance of a Certificate of Ocaupa ney. (/�,p
VY'aap.NYYYt
Owner or authorized agent Date ,TOTAL. ,(IV ISSUEDBY: s �7— OI11 UC r
OFFICE COPY