21962 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Address: 21962
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rare a one: APPLICATION SUBMI17AL DA fE
t�kOA6(4 CITY OF CUPERTINO-BUILDING DIVISION
?_ c°" a r. sate: y Lk.Nn: 'APPLICATION /PERMIT' t
BUILDINGFT.ECTRICALPLUMBING-
Lic.Na MFJCHANICAL CATEGORY CONTROL#
ArchlteR/Engineer.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby afflrtntlut lamlke3.fthorder provWoreo(ChapteC d,am enc APPLIANCESRESIDENTIAL �C, RBTHON
Ingweh..fou farce of Dl affect
(NeBusinessand ProfeselonsCode,and my
Iicenseie Mass farce deflect PANELS
LlcenseC % LIc.N
Date G°MT.Rar
ARCHITECTS DECLARATION - 201-IODOAMPS
qqq�000C ]understand my glare aha8 be used as pubBcrecoNe. OVER 1000 AMIs5 �.FT.FLOOR AREA $/SQ.Ff.
bU Licensed Professional SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIAL C"'LU7T/MISC
IherebyafBrmthat l am exempt fromthe ContractorsLkense LAW for the
02—A following reason.(Section 70315,Business and Professions Code:My city or
p4^� countywhich reclaims.Permit tomnstmct,alter,improve,demolish,orrepalr IEMP.METERES POLE INST.
m�m anystm=mprtortaiWb amc alsorequrestheapplimntfmsuchpermltto ROWER DEVICES
K file a signed atatement that M b licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(cemmencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC VALUATION
COQ Mon 3ofthe Buslnessand Prefessioru Code)orthat he b exempttherefromand
Q.•x..11 the basis for the alleged exemption. My violation of Section 7031.5 by any OUTLETSSWITCHESFI%T'UR I
applicant fora permit subjects the applicant to a civil penalty of net more than7,14
G
live hundreddollarsof thepr). - - NEW RESIDENTIAL ELECTR SQFT. ES 'TYPE CONSTRUCTION
QQQQQQ I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure is not Intended or offered for
sale(Sec.7044,Business and Pmfessimu Code:The Contractors License Law
�$ does not apply to an owner of property who builds or improves thereory and OCC.GROUT' RFS.UNITS
who does suchwerk himselforthmugh Ms own employees,provided that such
improvements are not intended oroffered forexle.If,however,thebuilding or TOTAL:
Improvement issoldwithinoneyearofcompietion,the owner-bullderwlll have
the burden of proving that he did net build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting wah licensed \ PERMIT ISSUANCE
contracture to censtruct the project(Sec.70M.Business and ProfesseimCode:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or improves thereon, and who contracts for such pipjects with a
�ghtactor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
l_J I am exempt under Sec. B&p C (or this reason BACK FLOW PROTECT.DEVICE
DRAINS.FUROR ROOF,AREA,COND. SANITARY Y N OUTSIDE FEES
Owner Date RECEOR p
I have a VSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAX Y N
out
l hereby affirm that I have a ceklfleste of consent to py tnwre;ora RpC�.at
cert lcabC.) rken'Comps/ri�sati�an�ir/uu�ranm ora certified cepythereof(Sec. GAS EA.575741-I INC.4 OUTLETS PARK FEE Y N
P�Nb C.) O s"` -�r�.Q 3 RECEIPT N
Com GASEA.SYS1TM.OVER4(EA) - - BUILDING DIVISION FEES
W�C�eriffled copy is heed with the
GREASE/INDUSI'RL WASTE INTERCEPTOR PLANCHECK FEE
fS'[Lerti(ied copy b filed with too city inspection division.
`/ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFp Date Recei t#
(fhisaection need not be completed If the permit is forone hundred dollars
($100)mlesa3 It {PATER HEATER W/VENT/ELECTR � � ENERGYFEE Y N
IceNm
rtifythat the performance ofthework(orwhich this permit is issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREAITNG
Workers'Compensation Laws of California.Date- PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQFp. Date Recei tri
Z O NOTICE TO APPLICANT:If,aaer making this Certlfiessof Exemption,you
should become subject to the Workeri Compereatlon provisions of the Labor - TOTAL:
N Code,you must forthwith comply with such provbima or this permit shall W BU
LU 7 doomed revoked. -
- CONSTRUCTION LENDING AGENCY SEISMIC FEE
ILDING FEE
CL
I hereby affirm that there is a construction lendingagency for the performs ELECTRIC FEE
TOTAL: ((��
Z ance of Lcadee.Namek(orwhlch this permit is iswed(Sec,3097,CIv.CJ xl/(J
LL O 'Lc.dce.Nana PLUMBING FEE ,
ly enaer.Aaareaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW loortllythallliv.m.dthisapplicallonandatilelhattheabovelnformation
1 le crerect.Iagree to comply with all city and county ordinances and state law. PERMIT ISSUANCE FEES PAID:
relating tobullaing cowtructlon,and hereby authorize representativesof this
Z city to enter upon the above-mentioned property fm inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL'
ag.het said City In cores
o" uence of the granting of this permit
� t �� AIR ITANDWNGUNIT(OVER]O,000CFM) CONSTRUCTION TAX
Signature of Applicant/ContraRor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfiwm building occupant store or hand le hazardous HEATING UNIT ITO 100,00(1 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Heaithand Safety Cod Tun 25532(x)7 HEATING UNIT(OVER IDD,"SM TOTAL:
❑Yea No
Will the applicant o re building occupant use equipment or devises VENTILATION FAN(SINGLE RESID) [SS TE
Which emit hazardous air contaminant.as defend by the Bay Area Air ��
l�J
Qua lily Management Distes rict? - BOILER-COMP OHI'OR 100,0(4)BTU) e1A�l
4YNo s�
have read the hazama materialsrequlrcmens under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Celifernla Health&Safety Code,Sections 25505,2S533 and 2:534.1 #ayg,•
understand that if the building does not currently have a tenant,that it is my NEWRFSIDEMIALMECH. - SQ.Ff.
responsibility,to notify the occupant of the requiremenewhich must be reset
prior to once of Certificate of Occupancy.
Owner or authorized Dateata
ISgl1ED S"Yl AA
TOTAL:
OFFICE COPY