21841 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Addresa:
PERMIT NO.
21841
S Ld (S d 976 /�j
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A A A
Contractor's Name: LIc. No.
UIBLDING-ELECTRICALPLUMBING-MFGHANICAL
CATEGORY
CO OL s
Architect/a'. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INF
PERMIT ISSUANCE
❑ ❑ ❑
Address:
LICENSED CON ACTOR'S DECLARATION
underprosiand of Chapter 9(mmmmc-
I Wreby oodommthat l Division
Ingweh5ectun 7000).f daffect. (the Buslmasand Pro(esslorasCade, and my
license Is in fuB force and affect.
MPLIANCFSRESIDENfTAL
PANELS
]OB DESCRIPTION
License Class
Date ractor
CoContnt
— UP TO 200 ANIPS
201-1000AMPS
ARCHITECTS DECLARATION
I understand my planes shall be used as public records.
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hamby. lrm that I am exempt frumthe Contractors License Law for the
following reason.(Sadhm 7031.5,Businesn and Professions Code: Any city or
county which reqrn
ula permit to construct, alter, Improve, demolish, orrepair
any structure prior to its Issuance, also requires the applicant forsuch permit to
file a signed statement that he is licensed pursuant to the prevbiow of the
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi-
.ion 3 ofthe Business and Pnefenlo. Code) or that he la exempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
appliont fora permit subjectathe applicant to a civil penalty of not more than
five hundred dollars %500).
❑ 1, as owee r of property, or my employewith wage as their wk
SPECIAL CBtCU1T/MISC
TEMP. METER OR POLE INST.
[OWER DEVICES
SWIMMING IDOL ELECTRIC
VALUATION
J
OUILEISSWITCHFSFTXTURFS
NEW RISIDENTIAL ELFfTR FI.
SQ.Fr.
-
TYPE CONSTRUCTION
compcnaaHon, will do the work and thexrocture Is not Intended or offered for
vie (Sec. 7044" Busbrss and Profeas mu Code: The Contractor's License law
does not apply to an owner of properly who Wilds or Improve thereon, and
who does such work himself or through his own employees, provided that such
OCG GROIII'
RFS. UNITS
improvements arena intended proffered fwmle. If, however,thebullding w
improvement bsold withinore ye...fcampletlon,the mvner-builderwfll have
TOTAL:
the rdenofpmvingthathedid notbuedorlmprowforpurposeofsals,).
I, as owner of the property, am exclusively contracting with licensedPERMIT
contractors to construct the project (Sec. 7044 Businea and Professions Code:
QTY, PLUMBING PERMIT FEE
ISSUANCE
PLOOD7ANE
APN
The Contractor's License law don not apply to an owner of property who
Wilds or Improves n
thereon, and who contracts for such pgojes with a
cCtd) licensed pursuant to the Contractor's License Law.
Kexempt under Sec B 6 P C for this mason
ALTER -DRAIN k VENT -WATER (Er,)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner ! - Date
ORmthatKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have ate of consent to ora
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RFCEIT g
FDnURFS PER TRAP
SCIiOOL TAX Y N_
op theure,
ceNBcateo(WorkersCompenaatlonlnauranawacertifled copy thereo((Sec.
o Insurance
3800, lab CJ
Policyan
RECEB'r N
GAS EA. SYSTEM -1 ING4 OUTLETS
PARK FEE Y N
Coy
CcrtfOed copy b herebyfurnished.thecity
❑ Certified copy is filedhere y city impetlion division.
GAS IA. SYSTEM-
EM -OVER
CREASE/INDUSIRL WASTE INTERCEPTOR
BUILDING FEES
PLANCHECKFEE
G ETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCESEWERSANUARYSTORM
Unot Wm
hissection need ncopleted lithe permit is (Drone hundred dollars
(S100)orlceJ in permRis fused,
[certify thatoy an person
1 shall not employ any person In any manner so a to became subject to the
dumperhavdvk so as to become
pca Com�nsatlon lawsof California. Date
Applicant
Certificate ofExemption,
NOTICEco
PAID
Date Recei t#
EA 2WF7,
WATER HEATER W/VENT/EIECTR
ENERGYFEE Y N —
PAID
Date Reeei tN
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT.
e, ubiCAtothe oricmaklom a
should become subject it the Workers' Compensation n provbfo. of the tabor
of the
Cada you must forthwith comply with such provisions orchis permit shall
dee
deemed revokN.
TOTAL:
BUILDING •E
TOTAL:
CONSTRUCTION LENDING AGENCY
w there i a co®troction io (Soc. agenry for the peAorm
1 hereby work
once of the work for which this permit is issued ($m. 3097, Civ. CJ
SEISMIC FEE
ELECTRIC FEE
Lander' N.
Lender's Address
T cenlfythat I have mad this application and satethat theabowinfomatlon
iscometl agree to comply with all city and countyordinancesand state laws
relating tobuildingcorsWctlon, and herebyauthorize representatives ofthis
city to enter upon the above-mentioned property fee inspection purpose.
(We) agree to save, indemnify and keep harmless the City of Cupertino
againstllab les, pdgments,costsand expenses which may In anywayaccrue
agairui s City In mWoo of the granting of this rmR.
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES
_ L(AID:
ALTERORADDTOMFLH.
AIR HANDLING UNIT TIO 10,000CFM)
Date Receipt
SUBTOTAL:
-
AIR HANDLING DnnT (ovFx to,BBoceM)
CONSTRUCTION TAX
�`pill/ln ,L` �.!/�C'r
YDate
Sig. ppecaAntb//c—olnt�ra-n`o�r
HAZARDOUS MATERIALS DISCLOSURE
E%HAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or handle hazardous
mxedal a de0nnd by the Cupertino Municipal Code, Chapter 9.1Z and the
Date RCOeI tic
Health and Safety Code�+. -S�ection 25532(.)7
❑ Yes u No
HEATING UNIT (OVER 100,000 BTU)
Tq L:
,
Will the applicant or future building occupant use equipment or devices
which emit havandom air contaminants as dented by the Bay Area Air
Quality Management District?
PYea he 1❑rZo
ardfet m ode, Se requirem05,2553and 25545.95 of
h Health
the California Health k Safety Code, Sections 75505, 25533 and 25534. I
understands llt the building does not cvdr.tly have a tenant, that cis my
nes; 1 to notifythew panto( the requirements which most be nrt
VENTILATION FAN (SINGLE RESID)
ISSU 'DATE
A �aa�
r•Ia fs' $ aL t/s/
/N,L`1 {y� yiBtt�1Q
BOILER-COMP(31OR IMOIX) BTU)
BOILER -COMP (OVW2I W,000 BTU)
NEW RESIDENTIAL MECH. SQ.F7
prior nceof a Certs eofOcrupancy.
uthoT6rd agent Data
7OTA L:
ISSUED BY:
OFFICE COPY