21594 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protest Identification I PERMIT NO.
Bul ding Address: 21594
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55 -7-7 CITY OF CUPERTINBUILDING DIVISION 1 �1 ,
Conmacto/s Name: Lie.No: APPLICATION / PERMIT 1
. n BUILDINGaECTRICALI'LUMBINGMECF ANICAL CAITL.ORY CONTROL 0
Architect/Engrver, Lic.No:
QTr'� ELECTRICPERMIT': .FEEBUILDING PERMIT INFO':
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm lhatlam Bceneed underp talons (Chaptor9(commenc- APPLIANCESRESIDENTIAL )OB DESCRJ[PHON
in wlth5ect1an7000)o(Divlalon3 ofthe Busi and fesslma'1 d2,andm
li¢n,se la In s 7" std dfeet. r' y PANELS
Liar. Cha — i Lk-is -
Date Contctor •`�
UP TO 200AM?S
CHITECTS records.
201-IOVER0000AM
AMPS
WO 2 I understand my plans¢hall be used s public remade. OVER 1000 AMPS �.FT.FL60R S/SQ,FT.
O Z SIGNSELFCTRICAL ,r.
Licensed
�Z OWNER-BUILDER DECLARATION SPECULCIICN hiLSC
L Thereby affirm that l am eaempt from the Contradoes License Law for the
following reason.(Section]W15,Buslneas and Pmfmlona Cade:Any city m, TFMP.MEfQt I ,'
Z IppS-'t��i countywhlchrequimapermitmmmt d,alter,impmve,demolhh,orrepalr
,4Canyslvcture pdorm its essuance,also requireatheappliant for such Ferman, WER DEV] \
_F 5 fde a signed statement that he as licensed punuant to the pmvbiom of the t
Cormadors License Use(Chapter 9(commenMg with Section 7000)of Owl- NG E
%`05' sion3oftheBualnmand Profmbm Code)orthatheuesmptthemfmmand V TION
-'yn 5 the basis for the alleged exemption. My violation of Section 70315 by any O ES
�'<i appH.t fora permit subjects thcappbc.t too civil penalty a one more than O t L�
q five hundred dolW($500). NEW I AL ELEC STORIES TYPE CONSTRUCTION
❑I,as owner of the Property,or my employees with wages as their sole
mmpewtion,w0ldothe work andthe stm=m h not intended or offered for
psale(Sec706gBusinesssed Profesiov Code:The Cmamciofs Licerue Law
does not appy to an owner of property who builds or i.p..thermsand OCC.GROUP RES.UMTS
whoduessuch work him lfm
orthugh hisownempleyees,provided that such
impmvemenm are nm Intended oroffered far ule.If,however,thebuilding or TOTAL:
Impmvementhwldwithin ovyearoicomptdioe,themner-buBderwill have
tisI,,.¢rrdenof provingthat he did notbu0d orimprov,forpurpmeofsaleJ. 'QTY.�.�',. ,'PLUMBING PERMIT •' FEE. FLOOD TONE APN
LI 1"as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntncton to construct the project(Sec 7066,Businm and Profesiov Code:
The Com adoM1 License law dm not apply to an owner of property who
Wild,or Impmves thereon,and who contracts for such PPjeete with a ALTER-DRAW k VENT-WATER(EN
�yLrr+ctor(g BmruN punuamtothe Gontradof.Licerae Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY'`
LJI am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,CONT). SANITARY Y N
Owner Data RECEIPT X
WORKMAN COMPENSATION DECLARATION FD(TURES PFR.TRAP SCHOOL TAX Y N
• ereby affirm that I have a certlBate,of consent to self-insure,or a RECEIPT
X
ce ;fItz(Wmkers Compensation lnaurance ora certified copy thereof(Sec. GAS EA.SYSTEM-1 WGA OUTLETS PARK FEE Y N
38M labC) RECEIPT
PolityY AA i� GAS EA.SYSTEM.OVER 4(EA) BUILDING DIV]SION FE ES
Ca
INI.LCe mply],4, y she . -�&A?A l PLANCHECK FEE
ertified copy is filed the city inspection division. GREASE/WDUSRiL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EV✓ER-SANRARY-STORM EA 1(XFT Date ReceI tN
(TNssedion need not be completed lithe permit Is for one hundred dollars
MM)erlesa,) WATER 1¢ATFxw/vEvr/o-ECTR ENERGYFEE Y_ N_
1 certify that in the performance of the work fopermit 1,the,perIe Issued,
I shall not employ any person in any manner m u to become subject to the WATER SYSIFM/TREATING
Workers Compensation laws ofCalffomh.Date PAID
Appl,.t Date Recei tq
Z NOTICETO If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLM°. SQFI'.
0 should become subject to the Workers'Compensation provlalov of the Labor TOTAL:
fA Cod,you rust forthwith comply with such provisions or this permit shall be BUILDING
j deemed revoked.
B o CONSTRUCTION LENDING AGENCY SEISMIC FEE
L Iherebyaffum that there h a construction lending agency for the perform TOTAL: ELECTRIC FEE
') Z ance ofthe workfor which this permit is Issued(Sec.3097,Civ.CJ IJO PLUMBING FEE
1ieender's Address QTY, .'' MECHANICAL PERMIT :ame FEE
MECHANICAL FEE
WIrmet.1 metatI nPly apphatynand dcuntethattheyordina aboveinformationlaws FEE PA
_ N mlatl. to rceg,..t diot,aBcity b ..th.ordinances gate PFdlMR ISSUANCE 1
atyment upong abo mn,aMhereby authorize representatives of this cei
Z dtyto est uponN above-memiovd property for Inspection purposes. ALTER OR ADD 7T)MECH. Date RCCCI IJI
(We)a ce to v e,indemnity an d keep harmim the City of Cupertino
agaorstlh illties,Jogments,cons ndexpenseewhI&mayinanywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again nal G' .segnenm the granting ofthis permR, CONSTRUCTION TAX
/ m .0 AIR HANDLING IINTL(OVER 10,000 CFM)
Signa n Appia /Contact r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuwm building occupant store or handle hazardous HEATING UNIT(170 100,000 BTI) Date Reeel t# if
material as defined by the Cupertino Municipal Code,Chapter 93Z and the -
Health and SaieyCode cion 25i32(a)? HEATING UNIT(OVER 100,0(10 BTU) TOTAL:
❑ Yes o
Willthe applicant future building ocmpanwse equipment ordevices VEN''TILATTON FAN(SINGLE RESID) ISSUAN a&
which emit hazard omab���aa1 fffo'''ntaminamsaa defined by the Bay Area Air
Quality Management D 7 BOILER-COMP OHP OR IW,=BTU) /
Yes No
have read the haze smaterials requlrcmvnts under Chapter 6.95 of BOILER-COMP(OV17100,000BTU) 4i•
the Czlifor us Health 8,Safety Code,Sections 75505,75533 and 15536.1 (,f
understan thatifth bulldingdonnamrrcntlyhaveatenanLthatitismy N'E'WRESIDENTIALMECH. SQ.FT. �� of p
responsibi cyto stat' •the oecvpan ofthemquimments which must be met
pn�or llo,' ance of Certificate a! snaps nry. L I 51
C,nelo uthort ent Date ISSUED BY,--\a— e(/ •
TOTAL:
OFFICE CGFY