21828 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
But o& Vey 21828
2era S ane. CITY OF CUPERTTNO-BUILDING DIVISION
dor' a : u=.Nn. ^1 APPLICATION /PERMIT
r �' `^ BUILDING- MECHANICAL-MECHAMCAL CATEGORY CONTIICO�
Ambltect/Engines Lic.No: rV
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PFRIVITISSUANCE I'z� LTJ 'yJ 1:1LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmn thatl amlicensed under provisions of , enc. APPLIANCES-RESIDENTIAL
In ection70)af ivision3 ofthe Buslnessand ProlesnonsCodeand my JOB DESCRIPTION
license 1,in full force and cited
Da
PANELS
License Clam LIc.r
Date Contactor IN IQ 200 AMES
ARCHITECTS DECLARATION M1-1000 AMPS
q�q�nv 07 I understa ed my plans shag be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA 5�/F[Q�.aFr.
Licensed Prdembnal SIGNS ELECTRICAL
<�<Eu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
HaGGi /hercbya(firm that am exemptfrom the Contractor's Lirense Law for the
OOvFI following mason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORIOLE IN
��� county which requirma pemuttocoretruct,alter,improve,dennlbh,or repair
anystmcture pdortolta bevance,also requlreslhe applicant for such permit to POWER DEVICES
O file a shed statement that he Is licensed pursuant to the provisions of the
Contradoes License (ChapterLaw 9(mm
mencin with Section 7000)ofDivi.
SWAMINGPOOL FdECRC
�3o I.r3.flheB.sinewandProfens
laCede)arthagheisexam therefromand A VALUATION
<S the basis for the alleged exemption. Any violation of Section 70315 by any 0 OUTLETS uSWTCHFSFIXTURESI_ZV V 3Y' Q
applicant fora permit subjects the applicant to a civil penalty d net more than 1 t
e.fy five hundred dollars(SSOO. NEW RESIDENTIAL ELECTR SQXT. RIES TYIPE CONSTRUCTION
0..
F11,as owner of the property,or my employees with wages as their sole
compensation,will clothe work,and thestructure b not Intended or offered for
psale(Sec.7044,Businessand Pmfemions Code:The Contractols Llceae Law
$� docs not apply to an owner d property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
whodoessuchworkhimself orthrough hisown employees,provided that such
Improvements arc not intended oroffered forsale.if,however,thebuilding or TOTAL: 11,00
Improvement atseld within one yeamf completion,the owner-builderwlll have
th,^�rden of proving that he did rat Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
L_j 4 a on,of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who
Wilds or Improves thereon, and who monads for such pWjeds with a ALTER-DRAIN VENT-WATER(EA)
c actor(s)licensed pursuant to the contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sec es
B k P C for that reav
OUTSIDEFITS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dale RFLEB'T/
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
F11 hereby affirm that 1 have a certifiore of consent to sel4lnsurc,ora REOEPT a
certiflcale of Workers'Coreperoation Insurance mamedfed mpythereof(See, GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800.Lab C.) /�/y fyy�' _QO —
Policy Y / 1 :t / RFLER'I'N
GAS EA.SYSTEM-OVER 4(EA)
' Com n4, Y of / BUILDING DIVISION FEES
[Decertified ropy is hereby furnished GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID (�-SAa�(
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 200FT Dale RCCCI l# -I.tJkGO
(Phis se tion need not be completed Bthe permit at for ore hundred dollars
(f100)ariess.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y_ N_
I certify that N the performance of the work forwhlch this permit is Issued,
I shall not employ any perwn In any manner ro a to become subject to the WATER SYSTEM/TREATING
worker;Compensation Lawsof California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date IZCcei t#
Z O NOTICE TO APPLICANT:ILaftar making this Certificate of Exemption,you
should become subject to the Workers'Compensation provblons of Labor TOTAL:
� (A Code,you must forthwith comply with such provisions or this permit shall be
BUILDING FEE CO
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl Q 1herebyaffirmthat there he a construction lending agency for the perform TOTAL; ELECTRIC FEE
M Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
o2 Lender.No PLUMBING FEE
LLLanders Addness QTY. MECHANICAL PERMIT FEE MECHANICALFEE L70
U l mnIfythatl have read this application and selolhatlhe above lnformalon .'Y
O W bmrred.IdgreetocomplywlthaUdtyandmuntyordinancesandstatelaws PERMHISSUANCE FEES PAID:
0. relating to building mmmudion,and herebyauthoriecrepresentathasofthis
Zcity to enterupon the above-rreNb d propertyfm Inspection purposes. ALTER OR ADD TO MECH. gsQ7
L) (We)agree t,eau,indemNfy an d keep the City of Cupertino
Date Reccipt#
agoWtlhbWtleoNdgmenat,coaand expenses which mayIn anywayameine
AIR HAFIDLING UNIT(T010,000 CFM) SUBTOTAL:
agaustsal city inns enceof the granting ofthls permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,ODOCFM)
—11-1
Signature of Applicant/Contractor Date EXFIAUST}IOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant or future building occupant store or handle hazardous HEATING UNIT(TO 10,00 BTU) Dj[�i�ARRE�CI t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Cede Section 25532(1)1 HEATING UNIT(OVER 101000 BTU) l;
Yes []ho
Will the applicant orfumVENTILATION FAN RESID)rebuildingoccvpantuse equipment or SS SINCE DATE
which emit hazardous.1,coeti m rams as defined by the Bay Arca Air
Quality Management District? BOILER-COMP MIT OR 100,030 BTU) (si
. 4Yes I—I No Y ;o
have read the hazy ous materials requimments under Chapter 6.95 of BODER-COMP(OVER100,00 BTU) Ana
the California Health k Safety Cod,Sections 25505,25533 and 25534.1 12 .JJ
u odersta nd that if the W lld Ing does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. '�T7. FEB
responsibility to notify the occupant of the requirements which must be met -
prior to Issuance of a Certificate of Occupancy. v
Owner or authorized agent Date
TOTAL: ISSUED BY
OFFICE COPY