21365 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Banding Project Identification I'FRMITNO.
2 1 3 6 5
tlunding Address:
3
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one: A A
. anr: _ CITY OF CUPERTINO-BUILDING DIVISION
anmanara Name: LIc.Na: APPLICATION /PERMIT [ l
BUILDINGELECTRICAL-PLUMBINGMECHAMCAL CATFL'ARY CONTROL N
• Archhe /Engineer. Llc.Nce
57 QTY ELECTRIC PERMIT -" ,FEE BUILDING PERMIT INFO
A PERMTISSUANCE ❑ ❑
LICENSED CONTRACT 'S DECLARATION
I hereby affirm that l am neensed under provisions of Cha pter 9(commenc APPLIANCFSRESIDENfIAL JOB DESCRB'IIDN
ingwlthSedion7000)of DiWgon3ofthe Busivesand Pwiessionscp e.and my
license hCho LICin hu= dfect. O�Sd/ PANELS
I= N
Date Contractor
ARCHITECTS DECLARATION 201-1000AMP5
i O Z I understand my pians shag be used es public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
%t�lj Licensed ProfessionalSIGNSEIECTRICAL
>>� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Iherebyaffirm that l ameampt from the Contractors License Law for the
following reason.(5tttien 7031 S,Businessand Professions Code:Any city or TEMP.MERE ORPOLE INST.
onentywhich requires a permit tommmuct,alter,improve,dermRsh,orcepair
Q any,t,nu pdort.i%t a=e,alsomqubestheappRantimsudipert tto POWER DEVICES
5 V file a signed statement that M b licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commencing with Section 7000)of Diel- SWIMMING POOL ELECTRIC VALUATION
05 con 3.f the Basin.and Profmbns Code)orthat he h eaemp"Innefromand
$' the basis for the alleged exemption. My violation of Section 70315 by any OUR.ETS SWITCHEiFIXTURES
S<5Q appb=tfora permit subjects the applicant to a civil penalty of net munflum
JOu live hundred dollars(S.5W1. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSMUCTION
I,as owner of the property,or my employees with wages as their sole
__< osmpcvaflon,will do the work and the structure is not intended or offered for
C❑ sale(Sce.70K Business and Pretenders Code:The Contractors License Law
$$ does not apply to an ower of property who builds or Improves therms,and OCC.GROUP RE&UNITS
who doesmch work himself orthrough hisown employees,provided that such
bsprovements arena Intended oroffered forsale.If,however,theb.0ding or TOTAL:
improvement bwldwithmoneyearofcompletbMtha owner-WBderwill have -
II,s.�ardeo of provingthat he did nmbuild orimpmve for purpose of sale.). QTY: 'h,� „r PLUMBIN6'PERMIT•1'd. .. 16FEE - FLOOD ZONE AIN
L�L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See 7096,Business and Professions Code:
The Contnnori License Law does not apply to an owner a property who AP,�-DRAIN&VENT-WATER MA)
builds or Improves ehermn,and who contracts fee such ptojem with a - FEE SUMMARY'- €
Cq�tect.n.)licensed pursuant to Um Contactors License Law. BACK FLOW PROTECT.DEVICE - -
]JI am exempt under SB&P C for thin reason
DRAINS FLOOR ROOF,AREA COND. SANITARY Y_ N_
Owner Dae RECEIPT N
WORKMAN COMPENSATION DECLARATION FDCI.URE_,PER SCHOOL I" Y_ N_
Ell hereby affirm that 1 have a certificate of consent to seBdrsvre,or a RECEIPT N
certieate of Workers Compensation ltuursnce or.mrtifmd Copy thereof(Sec. GAS EA.SYSIFM-1 WC.60ITILETS PARKFEE Y N
P ry#b CJ In'J 0,a ��� 3 RECEIPT N
GAS EA.SYSTCh1-0VER 4(EAI BUILDING DIVISION FEES
CC:"xd copy b hereby fumished. ` GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E3CcrtBied copy h filed with the city inspection division.
CERTMCATEOFD(OvIPfION FROM WORKERS' - GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2NE r Date Recei tri
(TMs senior,need not be completed lithe permit Is for one hundred dollars
(5100)mlm.) WATER HEATER W/VEM/ELECTR ENERCYFEE Y_ N_
I exrtlfythat N the performance of the work forwhich thus Permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers Compensation Laws of California.Date
Z Appeant NEW RESIDENTIAL PLMB._SQ}T. Dale Recei IH
7 O NOTICE TO APPLICAM:If,after making this Certificate of Exemption,you TOTAL:
t t
should become subjeco the Workers'Compensation provisions of the Labor
N Cade,you mast forthwith comply with such provisions or this permit shall be BUILDING EE
dimmed revoked. SEISMIC FEE
It CONSTRUCTION LENDING n AGQ:CY
I herein work
for wichthacomitunisumi( n a en forthe r(orm ELECTRIC FEE
L F3 ya S B CY R TOTAL:
7 Z once of the work(or which this perrtdtbteved(Sec 339'/,CIv.C.) `� PLUMBING FEE 00
O Lenders Ne me MECHANICALS PERMIT ',FEEn'
F Londersnddn-ss MECHANICAL FEE
WI certifythat l have read this appliationand aatethatthe above inhumeti0n FEES PAID:
a iscorrect.Iagree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE
Natingtobulldingmnstmaion,andherebyauthor representativesofthis
N city to enter upon the abovo-menttoned property for Inspection purposes. ALTER OR ADDTO MECH. Date Recei t#
? (We)agree to ave,Indemnify an d keep harmless the City of Cupertino
againstllabiWies,pdgments,cogsand expenses which may u Jinywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
gadcity is mooeemm f the granting of this permit. CONSTRUCTIONTAX
AIR HANDLING UNIT(OVER I0,000 CFM)
Signe.reof Apphca.t/C.rmcjPft Date ( EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant or future building occupantstom or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety CNI Sc n25532(a)7 HEATING UNIT(OVER IOD,OD)BTU) TOTAL:
Yes o
Willtheappllant Wtum building occupant use equipment ordevices VEIJ7ILATIONFAN(SINGLE RESID) ISSUANCE DATE
which emit hazardou bmmamivnuasdehmd bythe Bay Area Air BOILER-COMP OM'OR IW,IXU BTU)
10111,11
Quality NUr tgemcnt Dut
Yes bo
ihavc mad theh r ous rvteriaLs requircrrcnK under Chapter 6.95 of R01LER-COMP(OVFR 1(IO,OW BN) � -
the California Health&Safety Code,Sections 25505,23533 and 25539. I JAN O�,�r
J
understand that if the building does not currently have a tenant,that it h my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be,met
prior to ante Atfiate of Occupancy, :� �..
nerorauthonmdagc Date - TOTAL: ISSI.MD V
OFFICE COPY