21529 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
aBuilding Add
�v8s�x4 94� 21529
ams: - one: A
«pZp co L39. CITY OF CUPERTINO-BUILDING DIVISION O^
Contractor's Name: Lie.Na. APPLICATION /PERMIT
O Lt.)0I'D-- BLnDINGELECTRICALMA MBINGMECHANICAL CATEGORY CONTROL 0
Archlted/Engineer. Lk.No: I .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSOANCE I��i ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L�']
hereby that licensed am erpmvbiansoerg A7 'LANCESRESIDENTIAL ]OB DLSCRIPr0N
IngwlthSedcon7D00)otDlvigo3aftheBuslmnandProfftsi.nsCmde,.ndmy
Iinhse is In full tarn Ind ���l�� PANELS
Llnnac(�Clam Lic.N
k. O
Date —`—�otdractor —UP TO 2DOAMPS
ARCHITECTS DECLARATION 211-IOOOAMPS
PopW±rcOWzp I understand my plans shall be used as public mord] OVER OOOAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
Licensed Professional ISIGNSELECTRICAL
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
zy, a I hereby affirenthat l am exempt from the Contractors License Lnwforthe
Q' o mureason.n.(Section 70115,Busineu and Profenluns Code My cityor
R �� ntywhkhnquU nFermitrommt Malter,bnpiove,de=hsh,ormpair TEMP.METER OR POLE INST.
anyslmcture prlormits lseuame,alserequbesthe applicantfor such permitto POWER DEVICES
file a signed statement that he fe licensed pursuant to the provisions of the
3µF. Contractor's License Law(Chapter 9(mmrmcing with Section 7000)of DWI- SWIMMING POOL ELECTRIC
OJ s1on3ofthe Susineuand Pmf..kma Coda)orthat he is exempt theefromand VALUATION
E1 a,..•77777 the lash for the alleged exemption. Any violation of Section 70115 by any OUILETSwSW1I.CHF&FD(T URFS l� U'QQ s Q^Vl
O
applicant fora permit subjects the applicaotto a civil penalty of not nmetlan — `
$ flue hundred dollars hepm NEW RFSIDENTIALELECTR SQ1.7 STORIES TYPE CONSTRUCTION
wfll❑I,ae owner of the property,d the my em tura in with wages r Their sok
com(Ecc.7K Bush, theworkfeadom Code:
is not Intendedo iofferedfor
qsale(gee apply to a nowand f property Code:The Contractors License Law
$ don no[applytork t.1 olthroug property who nemporimproves thromr,ovidedthat and OCC.GROIIP RFS.UMTS
whodoesn0workM telfethroghhieownemployees,protheedthatsuch—gor
Improvement fared within omyeaioerectplMio tLhower-buileerwilI have
TOTAL:
Improvement bsold within omyearo(completion,tM1eowner-bulklerwlll have
t rden of pmving that he did not build or Improve for purpose of safe.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
eLI,as owner of the property,am exclusively contracting with licensed
contrectors to mmtmct the project(Sec.7044,Business and Profeniom Code: PERMIT ISSUANCE
The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN kVENT-WATER(BA)
Wilds or Improves thereon,and who contracts for such pkojem with a bFEE SUMMARY
actor(s)linnsed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,CONT. SANITARY Y N
Owner Dale RECEIPT 0
WORKMAN COMPENSATION DECLARATION FIXTVRES PER TRAP SCHOOLTAX Y_ N_ -
Of hereby affirm that I have a mrtificam of consent to self-Insun,ora RECEIPT N
nrtifimteofWorkm'Compematlontmurmmoranrtified copythereof Sec. CAS F.A.SYSTEM-1 INC.40UTLEIS PARK FEE Y N
Policy p lab CJ RECEIPT N
PolleGAS EA.SYSTEM-OVER 4'(EA)
Com any BUILDING DIVISION FOES
�CertNed copy is hereby furnished.
thdry e
ry
Certified ropy V(fled with Ninspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANCTARY-5I'ORM EA.200FT. Date RCCCI t#
(Thissectlonneednot becompleted lfthe permit i forom hundreddollars
(5100)mlWATER HEATER W/VENTJELECTR ENERGYFEE Y N
Imrtifyththat In,the perfomannof the work forwldch this permit is issued,
I shall nor employ any person In any nvnner so as to become subject to the WATER SYSTEM/TREATING
Worken'Compensation LAwso(Callfomla.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Re i t#
Z Z NOlicant APPLICAM:I,after maWng this Certificate of Exemption,you
should bamme mbject to the Workers'Campematlon provisions.(the Labor TOTAL:
CCN Code,you=at forthwith comply with such provixons orthis permit shall be IN
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d e Ihembyaffirmthat there is a mextmction lending agency for the perform ELECTRIC FEE
0 O ance Lender Nwork!ore which permit (See. CIv.C.)
TOTAL:
LL Tendo.Name PLUMBING FEE
L) I<nders Address - - QTY. MECHANICAL PERMIT FEE
O W Imes, these I agree tocom comply
is with allotyand stwy or ir.n oV,dat.el.ws-ronation MECHANICAL FEE
1 minting
intin to building
complywo ,andll hereyaunty9oe reprmsand statelawe PERMIT ISSUANCE FEES PAID:
} W dty togtobuponge above Manddproprty otl in nprexnbitives purposo(thls
F tltyWenterectosave love-memlomd property harmless
Cit purposes. ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify an d keep harmlen the City of Cupertino Date Reeei t#
V agaWtllabWtlas,jadgnanrs,metseM expenses wM1kh may lnmy wayamue AIR IIANDWNGUMT UO 10,000 CPM) SUBTOTAL:
ag;lid City in conaaryenec of the a this permit.
6 � AIR HANDLING UNIT(OVER 10,000CITt) CONSTRUCTION TAX
gIpollum.fApplicardtracto, Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:'
HA OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdous HEATING UNIT OPD 100,000 BN) Date Recei t# '
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 75537(a)? HEATING UNIT(OVER 1W,00)BTU) TOTAL: 4
❑
Y. u No
Will the applicant or future building occupant use equipment or devise VENTILATION FAN SINGLE REBID) ISSUANCE DATE
which emit bavrdous air contaminants as defined by the Bay Area Air �/►��
Qua lity Management District? BOILER-COMP OHP OR 100,000 BTU) RAW ,
Yes • O No
In have read the haaardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000BTU) DEC
O �Qeo
the California Health&Safety Code,Sections 25505,25533 and 75534.I DEC s99
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MICH. SQ.I7
responsibility to notify the occupant of the requirements which muat be mnt
prior to issuance of a Certificate ofOmpancy. -
Owner or authorial agent Data
TOTAL: ISSUEDBY:
OFFICE COPY