21044 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERhRTNO,
Building Address: 21044
/7 E�
secs area: A A
/LL�3 APV$Gi �'- CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: .,i• Lic.N. APPLICATION / PERMIT S-e V7, 119 U
Toth CUA>I lZ BU LDINGELECTR CA4PLUMBINGMEC AN CAL CATECARY CONTROL X
:trchited/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERbRTISSUANCE ❑ ❑ ❑
LICENSED CONTRAROr pr DECLARATION
I hereby affirm that)Division
ofthe erprovand Pro Cbapter9de,a;d c APPLIANCFSRFSIDENML JOBDESCRQ'TION
Ing with Sedan force of Divfect. fthe Buslnnsand Pro/neloreC�e,a�d my
license is In full force and c.# PANELS
License Chas Lk.M 3.
Data Contractor UP TO 2DO ANTS �}T�T� UU 10 1��AS KyL I I
ARCHITECTS DECLARATION 201-1000 AMPS
�
rs 7� I understand my plans shall be used as public recdrds OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.F r.'
I�U Licensed Professional i ,- SIGNSELECTRICAL
6 m
OWNER-BUILDER DECLAHATION-
7 Iherebyarm that lamexempt fromthe Coritr am- Llrenx Law fwthe ���LCIXCUIT/M1SC
ffi
oo following reason.(Section 70315,Bualness and Prolessbna Cade:Any dty or
OZF.f� TEMP.METER OR POLE INST.
F� countywhkh requbnape tocowtruct,settee,Improve,dennlbh,or.pair
q .-I anystructure prlorta its ance,aleo requlresthe applicant(wauch pU tto y
4n�y V fl4 a signed staterrent t t he'h Iloenaed pursuant to the prowl1ss'lore of the POWER DEVICES
�p?5$.Om Contractors License Law Tae,erg(mmmendngwith'SettWn7000)ofDivi-
I:,K05 elon3of the Businessand 11��ooffessiom Coi.e)orthat heuexempttAerefromand `fM1NG POOL ELECTRIC VALUATION
a^Sn" the bash for the alleged ePxmprtion. Any Wolatlon of .Mon Jm15 by any -
re than OUILETSWR
STCIiESFIXTlJRES 000--
�r5, ¢� appllcant(ora perMtaubjects lM1eapplkanitoadvll penaltyof ofnn
p, Ove hundred dollars(5500). f
NEW RFSIDI7JTIAL ELECTR
�.. �I,as owner o(the property;pr mye ployen with wages stheG Ie �'�' SIOWGS 7Y1'E CONSTRUCTION
�ZQ mmpcvatlon,w111dathe work anTl tAiswctvre boot intended r,o(feie
5 fffY❑ sak(Sec.706y eualr�eu and Profe.f�.lom Cade:Tse Contra is (cense Law
j$ does not apply to en owner of property who buil or 1 rcon,and
c- whodoessuch workhimselforthrwgh hisowne 1 -e s• 1 thaleach OCC.GROUT' RFS.DhTI'$
improvemenbare not Wended m cdf, to ut fh�wev,the uildingor TOTAL:
Improvernamissold withNoneyearofc 1 N eovener-builderwlilhave
Qtr Jgr not proving that he did not bull Isop vefnpurposnolsak.). QTY. PLUMBING PERMIT FEE FLOODZVNE APN
]ll(�y�'-r,as owner of the property,am ex Ively trading with licensed ppRISSIIANCE
don to construct the project(Sec.7 Business and Professions Code:
Contractor's License Law don rad apply to an owner of property who ALTER-DRAIN&VENT-WATER[EA)
builds or improves thereon, and who contracts for such plojects with a
og0.t{actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT. FEE SUMMARY
LI I am exempt under Sec. B &P C for this reason
Ower Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N—
ftELEfIT R
WORK MAN COMPENSATION DECLARATION FO(717RES-PER TRAP SCHOOL TAX Y N
01 hereby affirmorkem that p have o lr ur ate of consent to spytheure,ora RECEIPT It
wrtiflrab C.) rken'Campemalion Wuranra oracertifled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
Policyab C.) PARK FEE y N
Policy R
It
CamnY GAS EA.SYSTEMAVER<(EA) BUILDING DIV
ISION—FEESCertified
copy b hereby tume city
�Certlfled copy b(fled with the ty Inspection ddivision. GREASEANDUSERL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFlGIE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYEA 20OFT Date Recef t#
(fhb section need not completed((the pert b toucan hundred dollars
Iwmrti
(5100) lese.)fythat in the performance o(the work for which thle permit is Issued, HEATER W/
u
, VENT/FI IN ENERGYFEE Y N—
I shall net employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
C' ,Warkers'Compensatkm Lxwsof Callfarnb.Data PAID
PP NEW RLSTDENTIAL PLMB. .FT. Date Remi t#
Z O NOTICE TO APPLICANT:If,after ma king this CeAfflate of Exemption,you —SQ
.FT.
become subject to the Workers'Compensation provisions of the Labor TOTAL:
CCN Code,you=at forthwith comply with such provisions orthb permit shall be
D deemed revoked. BUILDING FEE .CDP
dCONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby affirm that them b a construction lending agency forthe perform : ELECTRIC FEE
Z ance ofthe worklorwhlchthb b permitLavred(Sec.3097,CIv.C.) TOTAL
U O Lenders Name PLUMBING FEE
IL h Iender'.Aaaress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imnl/ythat l have read thbappliwtion and statethatthe above information
6 iscorrect.I agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorlu representatives ofthis
I— Z city to enter upon the above-mr.tkned property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,indemni/y an d keep harmless the City of Cupertino Date Receiptp
against liabilities jrdgmenb,coetaand expe awMch may inanywaee accru AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against aald 91 nsryue fthe ling a this permit.
AIR HANDLING UNIT(OVER 10,(00 CFM) CONSTRUCTIONTAX
SmtureofAplicanl/Contract , Ex]-uusrHOGG(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC OSURE
Will the applicant or future building occupant store or handle hacardous HEATING UNIT(70 100,000 BTU) Date Rceef 1#
naIrrial as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I❑t yes Safety Cada SSelction 25532U)? HEATING UNIT(OVER 10,000 BTU) TOTAL:
Will the applicant or rotate building occupant useequlpment orcievices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
-� which emit havrdousafr contaminants.,defined bythe Bay Area Air _
Quality Management District? BOILER-COMP OHP OR IDG DM BTU)
4 Yesn No
havr read the hav ous nuterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ��n®
the Califs 1.11nith&Safety Code,Sdiom25505,75533and75534. 1 7
understand that ifthe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.F7.
rnponsibllitytondilytheoccupantofthe quirements which must emet
prior to issu o CertificaI fOccuv my y
f'/r�9e EP 1 '� iy90
Owner or authonmd agent /r )(ata, ,
TOTAL: ISSUEDBY: I
�: 7il'T
OFFICE COPY