21862 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
,. Building Pro«t Identification PERMITNO.
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' 267— CITY OF CUPERTINOBUILDING DIVISION Zb -_q /
Contract. Name: sae.N.: APPLICATION /PERMIT Z— C 1
' red r BUILDING-ELECTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL N
Archlten/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOU
Address: PERMITISSUANCE (NA ❑ ❑ El
CONTRACTOR'S DECLARATION I�
I hereby affirm that l am licensed under pmvislons ofChapter9(commmc- APPLIANCES-RESIDENTIAL JOBDF5CRI11ION
Ingwllh Section 7000)of Divig e,n3ofthe Bminesaand Professions Code,and my
license la in full force and effect. PANELS
License CsssLle N
Dae Contractor Ul!TO 2DO AMPS
201-1000 AMPS
ARCHITECTS DECLARATION
NO 2 I understand my pions shall be used u public records. OVER 11X10 AMTS SQ.FT.FL SQ.FT.
O
�'i Licensed Professional SIGNSELECTRICAL
Q OWNER-BUILDER DECLARATION
j Ihereby affirm thatI am exempt from the Contractor's License Law for the SI'ECIALCRCUIT/MISC
following reason.(Section 7015,Business and Professions Code:Any city or
O F TLMP.MECER OR POLE[NST.
county cture requlroapermlttomwtwctiresth applicant
to
F 4j any swcture priorttatemoibbat he Is also rcgpursuant to the rovixior hpeof to ppyypR DEVICES
V floe a algned ncens eLa that he t r9lic(commencing
pursuant to the tion MO) of the
Y�Ou, Contractor's Lkenselnd PC epter9(mmmenchathe eS mptthemfomaM
OS slon3oflhe Buainessand Professions Code)orthat hebexempthere(romand SWIMMING IX70L ELECTRIC VALUATION
yd•s Y the bass far the alleged exemption. Any vI.Ig an of Se tbn 7m IS by any O TILETSSW TCHFSA R RFS Y f/Q O
G� applicant fora permlt subjects the applkanttoacivil perky of not mom than .J _ s
fav=h)(ndred dolUn(550(). NEW RFSIDENTLAL ELECTA
en as owner of the property, `�� STORIES TYPECONSTRUCTION
persap perry,or my employees with wages r their sole
C7Q
men re
wWdothe so.rotwork and the stmcturebn ontracded orofferedLaw
cele(Sec.7044,B..bess and Professions Code:The Cantnctots Llcesue Law
{�$$ does not apply to an owner of prupetywho Wlldsor improves thereon,and OCC.GROUP RES.UNITS
E whodomauchwork himselforthrough his own employees,provided that such
Improvements arc not intended oroffered for sale.If,however thebullding or TOTAL:
improvement baoldwithln owyearofcomplctiomtheowner-buRderwill have
th,*rden of proving that he did not Wild or improve for purpose ofsele.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM
or Improve thereon,and who contra for such p�ojets with a
cccc'ggqqBBBBffIf((I(act�ortrms)jBTcenxd p�uyrsusa,nrt to the Corm.doe.Licenu Law.Date BACK FLOW PROTECT.DEVICE FEE SUMMARY
1 B&P C for this reasonOUTSIDE FEES
Ow er' - 1L{�f r^ DRAINS FLOOR,FLOORODF,AREA,COND. SANITARY N
F9
• Y_RECT N
g
WORNAN COMPENSATION DECLARATION FD(TURES PER TRAP SCI IDOL TAA Y N
1 hereby affirm that I have a certlfiote of consent to self-Insure,ora RECEIPT N
cetificeteofWorkesi Comp,..ti nlnsurarxem.certified ropy themof(Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N
3800,Lab Q
RECEIPTN
C. tl CAS M
EA.SYSTE .OVER 4(EM BUILDING DIVISION FEES
Com any
ECertifxi copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF UEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SAM.I.ARY-610RM FA pBFI. Date Recei t#
(rhlssection needot nbecompleted tithe permit b forons hundred dollars
($100)oricss.) WATTR HEATER W/VEM/EL[CTR ENERGY PEE Y_ N_
I certify that In the performance of the work forwhich this permit Is Swed,
1 shall not employ any person In any manner ro ns to bemnn wbject to IM WATER SYSTEM/TREATING
Workers Compensation laws of C+Bfomla.Date PAID
O Applicant Date Recei t#
Z NEW RESIDENTIAL PLMB. SQFT.
Z O houdbNOfICE TO subjed APPLICANT If,after making
om a Certificate is Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
�) Code,you=at fort hwith comply with such proWions or this permit shall be
BUILDING FEE _ U6
> deemed revoked.
W _ CONSTRUCTION LENDING AGENCY SEISMIC FEE .SO
R I hereby affirmthat there baconstrutlon lending agency for the perform TOTAL: ELECTRIC FEE
7 Z ance of the work for which this perent b bsued(See.3097,Civ.C.)
O O landess Name PLUMBING FEE
U. lender's Addrem QTY.I MECHANICAL PERMIT FEE MECHANICALFEE
U lutlfythatlhavemadthbapplknlonandaatethattheab.veinformation
O W isconect.I agree to comply with all city and county ordinances and gate laws PERMITISSUANCE FEES PAID:
1 reI.ti.gt.buildIrgcmvtmtlm,,..d Mrebyauthodzempreuntativeaofths
I— N city to enterupon the above�mentlomci propertyforimpectionpurposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnity an d keep harmless the City of Cupertino Date Retelpt#
V against liabilities,Iudgments,cogs and expenses which may In anywayaceue AIRILANDWNCUNFF(TOl0,000CFM) SUBTOTAL:
against+ ac' aonp+e of the gr.Qpng of permit. CONSTRUCTION TAX
�/ AAHANDLNG MI(OVERIO,000CTI
"A CONSTRUCTION TAX PAID:
Sig of pp t/Contractar� Date EXHAUST HOOD
HAZARDOUSMATERI LS DISCLOSURE HEATING UMT(T0100,000UN)
WI the applicant or future building occupantgme or handle hazard... Date Retel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the N
Iiealth+nd Safty Code Setion25532(a)t HEATING UNIT(OVER 100,000 BM TOTAL: vX .
Fly. , MN.
Will the applicant or future building occvpantuse equipment mdevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• QualityMarwgementD'uttct7 BOILER-COMP DIIPQRl00,IX10BTU) PAID
Yrs 2nus 6��1�
nava read the haza7oua materials requirements under Chapter 6.95 of BOILER-COMP(OVFltIW,000BTU)
the Glifomia Health&SafetyCode,Scc,imw SSQSM&13 and 25534.1 Cuu p 61991
sanderstandthatifthebuildingdoesnamrrentlyhaveatenanLthatltsmy NEWRESIDENTIALMECH. SQ.PT. ITNK pj
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate ofOccupancy.
CIb�Cupg�''�e
Owner or authorized agent Date TOTAL: ISSUEDBY:
OFFICE COPY