21517 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.11I Project Identification PERNITNO.
Building Address: - 21517
iz� 77- O/Z
,xr me. one. A A
OC CITY OF CUPERTINO-BUILDING DIVISION
can aor'aNam: Lie.No APPLICATION / PERMIT C
BUILDING-ELECTRICA4ML BING-MECHAMCAL CATEGORY CONTROL N
Archltea/Engineer. e _ LIc.No:
TY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
herebyaffirmthat lamdder provisions ofChapter 9 APPLIANCFSRESIDEM7AL JOB DESCRIPTION
IngwithSection7000)0(Dlvisd=3 afthe BusinessandProfessionsCodie,and
my
11¢nse Is Info land dfeR. r PANELS �7 /
License Gla»/�/ Lie.p G S d /`t�� Z.XO �C/`
Date_¢2 1/ Cont_tUP TO 2DDAMPS
9ARCH ITECI'SDE AfJO. 201-1000AMPS
7. I understand rrry plata shallbs used as public records OVER TODD AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
O
Licensed Professlorsl SIGNS
PECIA ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCIIT/MISC
1.., Thereby afflnnthatlam exempttrain the Contractor's License Law for the
07.21—� following mason(Section 70315,Businessand Profemlon.Code:Any city or TEMP METER OR POLE INST.
q4muntywhich requlresa pemuttommtruct,alter,improve,demolish,orrepalr
(S s anystmcture prior to its Issuance,alnorequiresthe applicant forsuch perMtto POWER DEVICES
E c Ella a signed statement that he is licensed pursuant to the prostiloru of the
Contractor.License Law tChiiImr9(carromming with Seaton 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
111...... O slon3oit's
Business and ProfessionsCode)orthat bels exempt therefromand
Sm S the basinforthe alleg d exemption. Any violation of Section 70312 by any
applicant for a permit subjectsthe applicant to a civil penalty of not mOUILETSSWITCIffSFl)ITlIRES
ore than l� lid 6 , C6
flue hundred dollars($500. NEWRFSIDENTIALELECTR SQFI. STORIES TYPE CONSTRUCTION
1,as owner of the property,or my employees with wages u their sole
rompensatlon,wRl dothe work and thestrocturc b not intended or offend for
7p Sc.It Bfl)d ssand Pians tons Code:The Contractors Lkmeelaw
$ does not apply to an owner of property who Wilds or improves thereon,and
$^ who doessuch worklameelforthrough hbownemployees,provided that such OCC.GROUIa RES,UNITS
Improvements are not Intended oroffered for sale.If,however,the building or TOTAL: 4
Improvement esoldwithinoneyearofcompla3aM theowner-bul ierwill have
tIgtu rdanofpromnglhat hedidno Wudorimprovemrpurposeofwle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
M L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mats&..to roretruct the project(Sec.7044,Business and Professions Code:
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN& -W TER(EA)
Wilds or Improves thereon, and who contracts for such p5ojects with a FEE SUMMARY
c?,gmtor(s)hcened pursuant to the Contractor'.License Law. BACK FLOW PR T.
I_I I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINSFLOOK ROOF,ARCA, SANITARY Y_ N_
Owner Dae RECEIPT N
WOR KMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTA% Y_ N
I ave a certificate of cement to self-Insure,o RECEIPT N
�Icate of Workers Compensatlonlnsunnceoracertifbd ropy thereof(Sec. CAS EA.SYSTEM-1 ETS PARKFEE Y N
500,Tab CJ RECEIPT M
rev
1'ollry p ified copy W hercbyturnbad' GAS EA.SYSTIMf OVER
BUILDING DIVISION FIBS
Com
CertGREASE/INDUSIRL WASTE I PLANCHECK FEE
' �Certified copy bfiled with the citylnspactlon division.
CERTIFICATE OF E0(EMP ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANHARY-STORM EA.200FT. DRIC Remi I#
(I"Immarn reed red be completed Bibs permit is foram hundred dollarsA.
(51(0)orless) WATER HEATER W/VENT/dECTR ENERGY FEE Y_ N_
I certifythat in the performance of the work for which this permit is issued,
I shall not employ an/person In any manner a as to become subject to the WATER SYSTEM/TREATING
Workers Compcmationlawaof CalRomla. Date PAID
O Z Applicant NEW RESIDLNTIi Date Revel t#
Z O NOTICE TO APPLICANT:IE after maFdng this Certificate of Exemption,you
F W a h.1dbecomesubpdt.the W.r .'Compe.tion provlalonsofthe Labor TOTAL:
Code,you must forthwith complywlthauchprovielovorthis permit shallbe BUILDING
a deemed revokedCONSTRUC ION LENDING AGENCY SEISMIC FEE 110
1 G I berebyaftlrmu4
thahem lata consuctton ismilegagency forthe perform ELECTRIC FEE
Z arw of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL
02 Lenders Name PLUMBING FEE
I— Lender's Address QTY. MECHANICAL PERMIT FEE
O W i curtlyNail havereadthb appbcaRongnd state that theabovelnformation MECHANICAL FEE
IL 01 Iscorroct.I agree to comply with al city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
lJ� relating to building construction,and hembyauthodze representatives,of thin
city to enter upon the aboecmentioned property for inspection purposes. ALTERORADDTOMECH. DatC Receipt#
(We)agree to save,indemnify an d Fiwp harmless the City of Cupertino
gat Judgments,costs and e} which may in an way accrue AIR HANDLING UNIT 10,000 CFM)
against g pen.ea y y y SUBTOTAL:
against said City in cons epic.of the granting of this permit. CONSTRUCTION TAX
AIA HANDLING UNIT(OVER tBLOOD CFM)
Signature of Applicant/Contractor Date EKHAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcant or future building meu pant atom or hand to hazardous HEATING UNIT(TO 100,000 BTU) Date Recej t#
material as defined by the Cupertino Mu mapal Code,Chapter 9.1Z and the
I health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,00)BTU) TOTAL: a�
❑ Yea M No
Will the applicant or future building occupant use equipmrat or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hezandom air conta minanb as defined by the Bay Area Air RAM,
' Quality Management District? BOILER-COMP DIP OR 100,000 BTU) B_
Yes E—]No
have read the bazarrdiowmaterialsrequlmmcnbunder Chapter6.95ot BOILER.COMP(OVER 100,000 BTU) 1[]Q(�
the Cali(ornW licalth&SafetyCode,Sealons 25505,25533and 25534.1 p ru; 7"s$O$11
undersWndthat lithe building does notcurrently have a tenant,that it bey NEIN RESIDENTIAL MECH. SQ.rT 1M"`
prix to bllitytonfa notifythe
otthe uircmeniswhkh mustW met
psponsi uance stay thea f e
OwIt, t Date ISSUF:DeY:�J CI[3Y�cuw ME.+Q..v—�-�v
TOTAL:
OFFICE COPY
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