21404 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identification PERMIT NO.
Building Address:
3 s 21404
sere ams:
C, A, Nj IN �- $_ G'2 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lii.Ni: APPLICATION / PERMIT
BUILDING-ELECnUCALPLUMBING-MECHAMCAL CATEGORY CONTROL at
Archite /Engineer. Lfc.No:
Q'y ,( QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AdQFesi R(�tJGA--$�lVhf U e SuitEl
J PERMITISSUANCE ❑ ❑ ® ❑
LICENSED CONTRACTO SDECIARATION
Ihembyaffimthat lam Bcensedunderprovisionsof Chapter9(co me APPLIANCES-RESIDENTIAL JOB DESCRIPTIONingwith Section 7000)of DIN,1on3oftheBminassand ProfessiensCOde,and my
license la in full force d c.# PANELS
License Clam— Cort PCZ., ".�—��_
Date Contractorf.��_ c-YfL�-x s
ARCHITECTS Dk LARATION 201-IODOAM15
a0 O I understand my plans be used v public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
x z Licensed Professional SIGNS ELECTRICAL
<<61 OWNER-BUILDER DECLARATION N I,..e
I..[� ; I hereby affirm that I-.exempt from the Contractor's License Law for the SPECIAL CIRCUIT/MISC - R `F �; ' 9 N
0- following reason.(Section 7071.5,Business and Professions Code:Any city or TEMP,METER OR POLE INSf. V
F� a countywhich mqufrva pernottocowtruct,alter,impmve,demolish,orrepalr 1
anystrucom priorto Its Issuance,also requlreathe applicant lorsuch permit to j / > / d.
O file a signed statement that he l licensed pursuant to the provisions or the �W DEVICES
w Contradorb License law(Chapter 9(commencing with Section 70M)of Divi-
sion3ofthe BuMnvsand ProfevWmCMe)orthatheiaexempttherefmmand SWIMMING IDOL ELECTRIC VALUA ON
the basis for the alleged exemption. Any violation of Section 7031.5 by any
5 OUTLETSSWTTCHESFIXTURES�—
fwe hu nd reds pears(subjma the applkant(o a civil penalty of nn rtnre Than
c.m five hundred dollars($500). NEW RESIDENTIAL ELECTR
�n ❑L as owner of the property,or my employees with wages v their sole SQtT SrOHfFS TYPE CONSIRIX:TION'
C7� compevatton,wllldothe workandtheatonurels not intended or oIferedf.,
5 O sale(Sec.7044,Business and Profenions Code:The Contractors License,law
$ does not apply to an owner of property who builds or imprwea thereon,and
F- whodoessuchworkhlnvelforthr ghhisownemplOyeeaprovldedthatsuch OCC.GROIR' RFS.UNITS
Improvements arc not Intendedorof(ered forsale.If,howe regthebuilding or TOTAL
i provementt wldwithinoneyearofcompiniogtheowner-buBderwiU ave
th,£burdenof proving that he did not build or improve for purpose of,ale.). QTY, PLUMBING PERMIT FEE FLOOD7DNE APN
U L as Owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors m common the project(Sec.7014,Business and Profeacumts Code: ��ry
The Contractors License Law does not apply to an owner of property who
buALTER
Wilds or Impronsi thereon, and who contracts for such p5nims with a DRAIN&VENT-WATER(EA)
col 0 (sI 0censed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec. B& P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,CONO SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATIONRECER'r N
`PI hereby affirm that I have a certificate of consent to self-Insure,w a 6 FIXTURES PER—TR" SCHOOL TAX Y N
cemficne of Wurken Compensation Imuranre ora certified mpythereor(See. RECEIPT N
38M pbQ - t7G GAS EA.SYSTEM-1 INCA OUTLETS PARK FEEP. Y_ N_
GAS EA.SYS!E-M-OVER 4(EA)
RECEIPT N
ComPPPPPPany + BUILDING DIVISION Fii ES
RICenified copy Thereby(urnlahe CREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE `
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhissection need not becompIMM lithe permit ls(oromhundreddollam SEWER-SAMLARY-STORM EA.200FT. Date Recd t#
(Sl M)orfeas.) ENERGYFEE Y_ N
Illnot that in the person
mance Of the Work nInanymannerw as
bco permit is to the WATER HEATER W/VEM/IB,ECTR
1 shall not employ any person In any manner ao u to become abject to the
O W Applicant Compensation]Awa of California.Date WATERSYSTLId/TREATIN'G PAID
Appllam
Z 0 NOTICETO APPLICANT-.If,offermaking thCoCenlflote of Exemption,you NEW'RESIDENTIAL PLMB._SQ,Fr. Date Recel t#
Fshould become subject to the Workers'Compensation provlaimis ofthe Labor
LL
W Code,you=at forthwith covs comply with such pmvbiuorthta permit shall be TOTAL:
dd kBUILDING FEE
5 eemeinvoked.
,d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I h fthe work for
that there i a comtoction lending agency for the perform
u Z Once o(the work!or whkhmhb permitbkswed(See.3097,Civ.C.) e�0,V
(� 2 I<Mcrs Name TOTAL �rl, ELECTRIC FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE a2G i C.C7
O W Icenifythatl have mad applkatlonand atatethattheaboveinformation MECHANICAL FEE
a tscorrectIagreeto comply with all cityand county ordinances and state law, PERMR LSSUANCE FEES PAID: I
} Yrs recorruto bullding comply with andty andcuntyorreancesndveaolaws
H city to enter upon the above-mentioned peer purposes. ALTER OR ADD TO MECH.
Z property for inspection u
V — (We)agree to save,Indemnify an d keep harmiev the City of Cupertino Date Receipt#
against Oabllitle,judgment,,comsand expeve..hlchmaylnanywaysocrue AIRHANDWNGUNIT(TO10,000CFM) SUBTOTAL:
aga�Old Cll In co�e of the�anting io thb i permit. ev
AIRHANDLINGUNIT(OVERI0,M0CFM) CONSTRUCTION TAX
Signanu�f Applicant/Contractor / / Di[' ExDAusr HoOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppilcant or tutu re building onvpant store or handle haeardous HEATING UNIT(TO SM,MO BTU)
material as defined by the Cuperti no Munlcipa l Code,Chapter 9.12,and the Date RCCCI t#
Ficalth and Safety Coir Section 25532(a)i HGTING UNIT(OVER IM,0W BTU)
❑ Yea n No TOTAL:
Wi1Hct haracant air corebuming tsitsdpant rund se equipment Amardevices VENTILATION FAN(SINGLE RESIU) I�a{{�J7}f�DATE
which emit ha>J rdoua air contamivnta as dellned by the Bay Area Air �°�
lity Management DuWn2 BOILER-COMP DFIPOR IMM,O BTU)
yes ®®No
have read the hazaidoua materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ? �
the CaliforniaaHealth&Safety Code,Sections 25505,25533 and 25534.I �4NU,-Aly,N
understand that lfthebulldingdonsnotromentlyhOve atenanLthiftitis my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met �{
priortonsuanceofa Cemf to of0 parry. N`rsy,c n,
�``
Ow er or au orivcd agent Date
TOTAL: ISSUEDBY:
OFFICE COPY