21411 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PEAMITNO.
Building Adder,,: - 21411
l LUNE"OVW ET
.- r sere: - one: q
i/O N C,eo c. 7-466 CITY OF CUPERTINO-BUILDING DIVISION �-/� �1
- Ce a;jName: Qyl�eN. APPLICATION I PERMIT `ems V
N LU Z0� BUILDINGFLECTRICALPLUMBINGMECHANICAL CATEGORY CONTROLM
Architect Engineer Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
paa� S�4A—StM.WV✓A[EE'D.� S.J,
PEAMITISSUANCE ❑ ❑ C� El
CONTRACTOR'S DECLARATION /�,-f
I hereby O)ofhat Di lkm3ofthe under
usinmandPmfions of h onsr9(mmmmc- APPL[ANCESRE9DENTIAL JOB DESCRB'TION
Ingwei Infull7000)of d efelon3oHhe Bustneuand Pro(eul.neC.de,and my A/irfolg Oe7lop .c
L A%Cn% thief«' flo 3 PANELS r�uN/%aM676X/tGe ✓I�GY/
Date Contractor /yp//1,(p - tbkSFr / I,Fa.W
ARCHITECT'S DECLARATION 1014000 AMPS .
M2 Iunderatand my pkushall be used an public records. OVERIODOAMPS SQ.Ff.FLOOR AREA S/SQ.FT.
L• Ltmneed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPEC ALCIRCUIT/MISC 1
Zf, 3 Iherebyafinn,'hat]am exempt fromthe Contractors License Law for the B..rED IN
following ma,on.(Section 70315,Business and Prcesslon,Code:Any dryer VTER
O TEMP.METEt ORIOLE INST.
�� caantywhlch requires.permitromnstwct,alter,bnprove,demolleh,orrepalr
anysMn mpdortoltslesuame,olaorequimtheapp0rantfmsuchper tto POWER DEVICES
Ne a signed statement that he in licensed pursuant to the provisions of the
O re Centractor's License Law(Chapter 9(commencing with Section 7000)of Divl-
fn slon3 olthe Budnessmd Prolessbna Code)orthet hek ezempt lhare(romand SWIMMING R70L ELECTRICI Nut pTION
5,
0 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES FIXTURE; -
applicantforapermitsubjectstheapPIANtA toe civil penalty of not more than
$ five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ917. S[O]BF5 TYPE CONSTRUCTION
�n ❑I,A.owner of the property,or my employers with wages as their sok
compenudorywllldothe work,andthe structure k na Intended or offered far
Osale(Sec.7044,Business and Pmfessfou Cade:The Contract.?.License Law
$ does not apply to an owner of property who bund.or improves thereon,and OCC.GRO[IP RFS.IIMTS
who does such work himself or through his ownempluyees,provided that such
improvements are not intended.roffered for sale.If,however,the building or TOTAL:
Improvement bsold within one yearofcmnpletion,the owner-builderwlll have
tha burden of proving that he did nor build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONEAPN
M L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to constrod the project(Sec,7044,Business and Pr.fevku Code: Zt 06
The Contractor's License Law does not apply to an Owner of property who ALTER-DRAIN&VENT•WATER(E,V
bulks or Improves thereon,and who morons. for such ptokcu with a FEE SUMMARY
contpctor(s)licensed pursuant to the Contract.?.License Law. BACK FLOW PROTECT.DEVICE OUTSIDE FEES
U I am exempt under Sec. B&P C for this recon
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N=
WORKMAN COMPENSATION DECLARATION R
QnI hereby affirm that I have a cerHOcate of comm t...1mnsure,m a ����P I� SCHOOLTAX Y_ N
cert mteof Workers•Compensatlonfuumnmmacertlfiedcopy thereof(Sec. RECEIPT
380D,Ieb C.) GAS EA.SYSTEM.1 INCA OUTLETS PARK FEE Y_ N_
RECEIPT 0
On M GAS EA.SYSEMOVER 4(EA)
Ca any BUILDING DIV]SION FEES
ertlfied copyishe-by furokhed' GREASE/EVDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certlferd copy k filed with the city Inspection divialon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWELSANffARY-STORM EA.700Ff. )RIC Recei tM
(Thlssection need not becomplated if the peanut bforona hundred dollars
(5100).,lees.) �ww ENERGY FEE Y
reblWATER FTEATER W/VFM/E.ECTR N
I rti(ythat In the performance of thewmk f.rwhlch this permit is named, V O
I shall nm employ any person m any manner w u to become wbjed to the WATER SYSTEM/TREATING Workers'Compensation law.of CaBfomla.Date . PAID
-
Z0 Z ApplicaNOTICE NEW RESID=AL PLMO._SQ.ET. Date Recel tk
O NOTICE TO esubje hotel after Workemakinrs'Compensation
this Certificate provisions
tof he
� should become.object to the W.rken'Compensatbn proWions ofthe Labor TOTAL:
N Code,you moat for hwlth comply with such provisions or this permit shall be G
FEE
W j doemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaflrm that there is a construction lending agency forthe perform- TOTAL: ELECTRIC FEE
M Z ance of the work for which thin permit k issued(Sec.3097,Civ.C.) - O
V O Leader'.Name PLUMBING FEE
LL F Lendse.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl have read this application and state that the above information
1 incorrect.I agmeto complywilh all cityand courayordinancesand state law. PERMITISSUANCE FEES PAID:
>. N relatingtobullding construction,and hereby authorize representatives of this
I— Z dtytoenterupon the above-mentioned property fee Inspection purposes. ALTERORADDTOMECH. Dale Recei tp
z (We)agree to save,indemnify an d keep harmless the City of Cupertino
against liabilities,Hdgments,mksand expensetwhich mayln anywayacoue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.gal id Clty I i caryencey f the�granting of this permit.
� z/+za� - x-91 AIR HANDLIN'GUNIT(OVER Icimilc ) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTT;) Date Recei to
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Code pion 25531(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant A.re building occupant use equlpment ordevim. VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit lurardous air contaminants as defined by the Bay Area pis
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4Y. No y
haus read the hazy oue materials requirements under Chapter 6.95 of BOILER-COMP(OVEi 100,000 BTU) L�
the California Health&Safety Code,Sections 75505,25533 and 15534. 1
understand that if the building does not currently have.tenant that it Is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirvmentawhich most be met JUN 4 O IP91
Prtort nceaa R to of panty.
.nem 7-9/
(TJior authorlud agent Data ISSUED BY
TOTAL:
OFFICE COPY