21929 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—VSE-BALL POINT PEN ONLY
BuBuildingProject
ilding Address:
Idedrificalon_ - PERFR7 N0.
X930 L�D. C�c �
21929
neva me: _ - A .
f�11.zi'13L APPLICATION A 4 2 CITY OF CUPERTINO-BUILDINGDIVISION 1 � A
meter's Name: ^ Lie.N.: APPLICATION I PERMIT
a, ( TyQTS Q`1 R�-T S Lie BUILDING-ELECTRICA PLUMBING-MECHAMCAL CATEGORY CONTROL p
ArcMtet/Engineer: No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: A-��
PERMITISSUANCE ❑ V1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
It...I hereby-(firm0)ofDthat I mlkm3.fth.under pcass.onaofmdomChapter 9(ro.rd.3 APPLIANCES-RESIDENTIAL JOB DESCRIPTION
With Se tion fore and effect. Buslneseand Pro(enelanaC�de,and my D
license is iafuB farm and effect PANELS
License Class LM.r -
Date Conhactoi UP TO 2DO ,
ARCHITECTS DECLARATION 301-10DOAMPS
O Iundentand my Fit--hall be used as public remrds OVERI000AMPS
SQ.FI.FLOOR AREAE�,IQ
a
z Licensed Pralesslorul SIGNS ELECTRICAL
OZ 2,-6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
❑❑❑ Iherebyaffi.that lamemerpt from the Contractor.License Law for the
1 following reason.(Section 7031.5,Buslnese and Profession-Code:Any city or
pv� muntywhichrequiresapermlttomvtrut,alter,lmpmve,demolbh,orrepalr TEMP.METER ORPOLE INST.
q a e-signed statement
that he is licensed
undo t to the provisions
permit to
^�gO file a signed rtce..Lt that he(Chapter 9(com pursuant to the pro 7000) o! the (OWER DEVICES
H E, sion3 Ofthe Liceme LawrofessCode)or tat with Section 70W)omand
t, � elon3o(the Boatloads and Profs-sbro Code)orthat hely exempt Nere(romand - SWIMMING POOL ELECTRIC � VALUATION
Y.' the bash Tenths alleged exemptbn. Any violation at SMion 70315 an
�� applcant(ora permit-ubjectsthe appllemttoa dvil penalty of no[more than OUTLETS-SWITCHES-FIXTURES
five hundred dolhn($500). ,.
❑I,as owner of the property,or my employees with wage-a their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTTON
7a compeneation,wRldothe work,and theatrocturels notlnlended or offered for
O sale(Sec.7046,Buslneea and Profemian-Code:The Contrarlors Llreme Law
'� does not apply to an owner ofproperty who Wiida or improves there
no,and .. ,
who does-uchwork himse8orthrmgh hleownemployees,,provided thatsuch OCC.GROIJP RES.UNITS
improvementeare not Intended oraffered lor.ale.If,however,the Wilding or TOTAL:
rmprovementbaoldwlthln oneyearo(campltion,theawner-bulWerwIII have
t Nen olproving that he did not bund or bnprove for purpose otask.). QTY, PLUMBING PERMIT FEE
u;as,owner o(the properly,am exclusively contracting with licensed - FLOOD,OD APN
rontracton to corutmRthe
Pro ject(SeC.7044,Businenand Professions Code: PERMIT ISSUANCE '
The Contnctor'e License Lw does not apply,to an owner of property who
Wilda or Improves[hexon,and who centras- for such prajecis with a ALM-DRAIN VENT-WATER(EA)
offetor(s)licensed pursuant to the ContraRorb License Law. FEE SUMMARY
L.�I am exempt under Sec. B'&P C for this reason BACK�W PROTECT.DEVICE
Owner Date DRAIN&FLOOR ROOF, COND. SANITARY Y_ N—
WORKMAN COMPENSATION DECLARATION RECEIT#
OW ❑1 hereby affirm that I have a certificate of consent to self-Insure,or a PIXTURF&PER TRAP SCHOOL TAX Y N
certificate
DI
o(Workere Compensation Irsurmce or certBled mpythereof(Sec. RECEIPT a
3. Lab CJ GAS FA.SYSTEM.1 INC4 OUTLETS PARK FEE Y N
Polley# - RECEIPT if .
Com any GAS d(E
GAS-FA BUILDINGDIV
Certified copy is hereby fumlahed. ]$IONFBES
Certlied copy I-filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS', GREASE TRAP PAID
COMPENSATION INSURANCE '
IThle.ectioe.red not becompleted l(theperent laforoaehundred delta, SEWER-SANITARY-STORM EA.300FT. Date Recei t#
'($100)orlth ENERGY FEE Y N
lll-achatlntany Poon many le mannrk(.,Whichad obecome subject
WATER HEATER W/VENT/ELEC7R N-
1 stall not employ any person In any manner an as to become subject to the
O Workera'CompenaaHan lawaol Cahfornla.Date WATER SYSTEM/TREATING � PAID
Z Applicant
Z 0 NOTTCETOAPPLICA .lf,aftermakingthb CeNflcateof FaempHon,you NEW RESIDENTIAL PLMB.abou:d become roviders,of the Labor SQFT. Date Recei t#
~ N Code,you mu at forthwith co ply with such providensation.or this pem,itshall be TOTAL:
W > deemed revoked. BUIL IG FLE
IL0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I hereby affirmthat there is a construction lending agency far the perform- ELECTRIC FEE
... fthe..,it for which this permit is Issued(Sec.3097,Civ.C.) -TOTAL:
LL O Lender.Name PLUMBING FEE
LL I- Lender.fythel QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W mdl ythatl havereacithisappli atlonand�ate thattheabove in(ormaHm
1 scorret.I agreete,comply with all city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID:
F- (D relating to building construction,and hereby authomm representatives ofthis
I" Z city to enter upon the Above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
V — (We)agree) save,indemnify a ep harmlea the City of Cupertlne Date Reeei t#
against flab 14e,judgmenb,rostra ex see which may In a/n(Yy ay esus AIR HANDLING UMT(T010,000 CFM) SUBTOTAL:
against. comae a ming of this permit!
14 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si nature of App cant/ContratorateI I EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as,defined by the Cupertino Municipal Code,Chapter 9AZ and the Date Reaei t#
Is. and Safety Cod o 75533G)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant c cure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)' ISSUAJNT^q)R�TE
Which emit hazardous air contaminants,as defined by the Bay Area Air X-8riV1
l u�_allty Management Diyptt7 BOILER-COMP QHP OR 100,000 BTU) • q Q
IT,Yea (�rJdI3No
have read thehaz us,materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Code,Sections 25505,75533 and 35534.I t
understand that!(the building do not corrently ,haveatenanL that It rs my NEW RESIDENTIAL MECH. SQ.IT.
rnportibility to notify the occu ant (lherequlrementswhich..at be met dsI{y a-{(su..d- 9f�
prior to • fa panty. 9aalAr V8}3 II'p .
Owner or authorized agen Date - n
. 'TOTAL: ISSUED Btu �J' -
OFFICE COPY