21527 (2) APPLICANT TO FILL IN INFORMATION WITHIN;RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuBding Address: 21527
ii�iaz 1 >q N nut Owe, -4 Svi
aces. APPLICA HON SUBMnTAU=.
W 0— — / CITY OF CUPERTINO-BUILDING DIVISION ' ��� p0
Contraetols Nance- IA,No: APPLICATION / PERMIT L
(0G 3BUILDINGELECTRICALPLUMBINC-MFCHAMCAL CATEGORY CONTROL a
Architect/Engineer. Lk.Na.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I'Q4MIT ISSUANCE ❑ Yj'. ❑ ❑.
LICENSED ED CONTRACTOR'S DECLARATION JOB
I hereby affirmthatlamgm3afheBug licensed under rovaAdPffhmarodeand c APPLIANCESRESIDENTUL ].O.B�D..Ea�SCRUa'ffON
Incense I.ecilon TOW)of Divfect. oftheBustnessandProfeaelonsCadeand my
license b In s farce and effect. PANELS
Lasses Ckw Clap
Date Contactor UP TO 2DOAMPS
ARCHITECI'S DECLARATION 30140DOAMPS
[e[fQ Z I understand my plan shallbe used eSpublic records. OVER 1 WO AMPS - SQ.FT.FLOOR AREA S/SQ.FT.2d O
Licensed Fmfe®bvl SICNSELECTRICAL
OWNER-BUILDER DECLARATION
"RERDEENTIAL
CUfT/MISC
t"' blob owing affirm that la 7031 Z,
(mmthe C Professio License Lw fort he
2o following reesen.(Sect10n 70315,BusInm and Profesolons Code:Any city or
IGpfa � OR POLE INST.
S acuntywhlre reyulesa pertNeromvreq.1mstIuaplicamfrsuch,ormatto
1 anyetrocture prbrroltebsuence,aleorequkesths appllant(m such permlttoPOWER DEVICES
L• file a signed statement that M Is licensed pursuant to the provisions of the
Gµ(- Contractor's License Law(Chapter 9(conurcncing with Section 7DOO)of Divi- VALUATION
s,30J ston3oftheBuslneamed Pmfm,dona Code)orthst hebexempttherefromandVOL ELECTRIC
<.•�77 the basis for the alleged exemption. Any violation of Section 70315 by anyITCHESF7%Il1RF5
pplicant fora permit subjects the applicant to a civil penalty of not more than
five ndred dollars(5500). - N:EW ELECTR SQFI' STORIES TYPE CONSTRUCTION
44 I, a owner of the property,or my employees with wages as their sole
m satlonwilldothework,mdtheswctumbnot intended or offered for
Osale(Sec.7044,Business and Pmfeatov Code:The Contractor's License Law
$ does not apply to an owner of property who builds or improves themon,and OCC.GROUP RES.UNITS
who doessurh work himself orthrough his own employees,provided that such
Improvements are not Intended or offered forsale.If,however the build Ing or TOTAL:IISU
Improvement b wld within omyearofcomple0oq the owner-bu0derwlll have
thcburdan of proving that he did net build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
n 4 as owner of the property,am exclusively contracting with licensed
mntncton to construct the project(Sec.7044,Business and Professions;Cade: PERMITISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VFM-WATER(EA)
Wilds car Improves thereon,and who mntncte for such p(ojects with a FEE SUMMARY
cgpjpctorts)Vmneed pursuant to the Contractor's License Law. wBACK FLOW PROTECT.DEVICE
_
I_l l am exempt under Sec. B k P C for this rean
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N_'
Owner - - Dale RECEIPT N
WORKMAN COMPENSATION DECLARATION FIGURES PER TRAP SCHOOL TAX Y N
❑[hereby affirm that I have• Insucete of consent to spytheure,ora RECEPT I
art0,abo(Worken Compenudonlvurancemacertifled copy thereof gee. GAS EA.SYSTIM-]WCAOUTLETS PARXFFR Y_ N
Policy
lab CJ RECEIPT M
Polirya GAS EA.SYSITM-OVER4(EA) —
Co�m aray BUILDING DIVISION FEES
11Cert1(ied copy k heed with hehed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
-L Certlfed copy b filed with the airy inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID ,
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA 200FT Date Recei t#
(Thleeectien need net becompleted I(the permit b(�r�ne hundred dollen _
(5100)orless.) WATER HEATER W/VENT/ELFLTR ENERGY FEE Y N
I certify that In the performance of thewerk forwM1lch this permit is issued,
I shall not employ any person in any manner an as to become subject to the WATERSYSTEM/TREATPIG .
Workeri Compenantion Laws of CAI fomb.Date PAID
O Z Applicant - NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
Z O NOTICE TO APPLICANT-.If,after nuking this Certificate of Exemption,you
fshould became subject to the Workeri Compewtlon provbiov of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions or this permit shall be
W 9 deemed revoked. BUILDIN FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. Ihereby affirm that there is a construction lending agency for the perform, TOTAL: ELECTRIC FEE
O ante ofthe work for which this perm097
it is Issued(Sec.3 ,C1v.C.)
I.endda Name PLUMBING FEE
U F Lender.Add rees - QN. MECHANICAL PER FEE
. O
W dmnifythatlhavemadthbappllationandatatethattheabovelnfomutlw MECHANICAL FEE
IL bcorrect.I agreero comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorlim representatives of this
F N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harndem the City of Cupertino Date ReCel t#
V against lkblVtles,Judgments,casts and expenses which may In anywayacnue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Against aid City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
D
Sigritureo(AppVanlA RDOactm Data EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
• HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building errant pant store or hand le haeardous HEATINrbNIT(T0100,000 BTU) Date Recel t#
materlal as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Ilalth and Safety Code Section 25532(x)7 .i HEATING UNIT(OVER 100,000 BTU) TOTAL: r
YNo
❑
WiiltaheApplicant m lure Wliding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haardous a4 contaminants as defined by the Bay Area Air
Quality Management District? MOILER-COMP DEIPOR 100,000 BTU)
.Ya ❑❑No
hovereadlhebazarecuertutcrlabmqulmrnenlsunderChapter6.95o( BO LER-COMP(OVER 100,000BTU) PAO
lib California Health A Safety Code,Sections 75505,25533 and 25534.1 � ,�^{ y �/s{
understand that if the building dos run currently have A meant,that It is my NEW RESIDENTIAL MECH. SQ.FT y ( logo.
responsibility to notify the occupant of the requirements which most be met CC'�M�F
prior to issuance of a Certificate of Occupancy.
Owner or authorlud agent Data TOTAL: ISSUED BY s,
OFFICE COPY