21482 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PUEMITNO.
Building Address 21482
Wne(a >mVV e G: APPUCACITY OF CUPERTINO6BUILDING DIVISION 1/T� / O
Nt
C raciorsN : p. APPLICATION 1 PERMIT / l
CSS C I VM BUILDINC-ELFCTRICALPLUMBING-MECIIAMCAL CATFCARY CONTROL M
Architect/Engineer'. Lic.No:
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITIWUANCEEl ElElLICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that am beensed under provisions of Chapter 9(comment. APPLIANCES-RE-RDENITAL JOB D RIPION
Ingwith Section 7000)o(DlNslon3oftheguslnessand PrefesslonsC-ode,and my
Livens is (o and t. I PANELS /�� �a
License Lass Contra`ZR �/ !/!'\l•/•
Date Contactor 1a
ARCHITECT'S DECLARATION 701-1000 AMPS
aO ZOO I understand my plans shall be used as public ramrds. OVER 1000 AMPS - SQ.FT.FLOOR AREA S/SQ.FT.
E t' Licensed Professional SIGNSELECTRICAL I Iii A L E D N
OWNER-BUILDER DECLARATION SPECIALCIRCULT/MISC ® U T R
o. IherebyafR mthatlam exemp from the Conte roe's License Law froths
following reason.(Section 70115,Business and Profession.Code:Any city or //��
O' TEMP.METER OR POLE INST. IIZ�I 'V
.r M countywhichrequires permit rommrequirsthe aImprove,demsuor ch,or repair
.�
any.tmcturc taprint
emeits hat he I,aborc d pursuant to the rovisk permit a (OWER DEVICES ATE
file a signed statement that k Is Rrenxd pursuant m the provIsloro of the
3Oy Contractor's Lrceroe Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC —
s, ..JJ77 sion3ofthc Business and Pmfc.I ru Code)mthat he h exempt lhemfromand VALUATION
�i S°_ the bash for the alleged exemption. Any violation of Section 7031.5 by any OU7LE755WITCHFSFlXCURFS
applicant/ora permit subjects the applicant to a civil perulty of not rtnre than
five hundred dollars(950(f. NEW RESIDENTIAL ELECTR_SQ.FI'.
1,as owner of the ro STORIES TYPE CONSTRUCTION
p petty,dtmy employees with r their
,7 mto&c.7lon,wlxter.andll dothe Prrk,ansion.,ndurche is Cust ttecim'nded o lmose offered for
S�❑ doe(Sec. pp:y Business and of property
Cade:Theo improves hereon law
�� does not apply torn ownerofprough whonemhe poyees,povide thereon,and OCC.GROUP RIS.UNITS
whodoeuentsamuch ktInten edorooghhlsowale.It owe,er,the uildbuch
Improvement am not Intendedorpf(eco (prole.theo eveplflderwdingve TOTAL:
Improvement Issold with)noneyearo(compldlogtheowner-budderwlll have
tisden of proving that he did notbuild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
64 as or of the property,am exclusively contracting with licensed ^
contractors to consumer the project(See 7044,Bushes a od Prefessloro Code: PERMIT ISSUANCE z'010
The Cers License Law deer not apply tan owner d propertywho Z ALTER-DRAIN k VENT-WATER(EN •O
bu Uor Imp
de or Improves thenen,and who matted. for such p(ojeM with.
CMIaexempt underpursuantSm to the Contnctor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf 1 am exempt under Sec B k P C for this reams
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT I
WORKMAN COMPENSATION DECLARATION FD(TURFS PER TRAP Aix SCHOOL TAX Y N
01 hereby affirm that i have a rertlliate of consent to xl!-incurs,era ,r/ (J RECEIPT I
_ ceMtinle a(Worken'Comperwtlenlrouranre ora rettl(kd copytM1ereot(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
3800,Lab C.)
FcdtryM �/$ /. pas - RECEIPT 0
Com env t GAS EA.SVS EMF OVER4(EA)
._}'yam• rIL BUILDING DI VISION FEES
Certified copy b heie6y�mle city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CD
ropy h filed with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR K ERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM(Thtsection need not becompleted Bthe permit Is(oronehundred dollars STORM EA,700Ff. Date Receipt#
(51W)mInss.) WATER HEATER W/VENT/ELDCTR ENERGYFEE Y N
I pettily that In the performance of the work for which this penult Is Issued,
I shall not employ any person In any manner so es to become sulejertto the WATER SYSTEM/TREATING l7 a
Worker'Compensation Laws of California. Date t IAIp
O Z Applicant NEW RESIDFNIIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:II,after making Isiah Certificate of Exemption,you
fshould become subject to the Workers'Compematlon provisions ofth.Labor TOTAL:
tl3 Code,you must forthwith comply with such provisions orthh permit shall be
> deemere
d voked. BUILDING '
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CI, Ihereby affirm that there Is a construction lending agency for the perform- •V t/ ELECTRIC FEE
Z .rses.(theworkforwhkhthhpermithIs ed(See3097,Civ.C.) TOTAL: V!/
U O Lenders Name PLUMBING FEE
LL H Lamise.Aadress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I caAlfythatl have read thhappllcats.e.ed&atethattheabove Information
S hrortect.I agree to comply with all city and county ordinances and Gate laws PERMITISSUANCE FEES PAID:
relating to building construction,and hereleyauthorlaereprc.entatly ofthh
Z city to enter upon the above-mentioned property for Inspection purposes, ALTER ORADDTO MFOH. pate Reeei t#
V _ (We)agree Weave,indemnl/y an d keep harmless the City of Cupertino P
against Babilliks,judgments,costs and expenses which may In anywayaatue AIR HANDLING UNIT(170 10,0D0CFM) SUBTOTAL:
agawt uldC In cones uanc of t re granting of this permit.
/ �f� � �� a�y�n AIRHANDWNGUMT(OVERIO,ODOCFM) CONSTRUCTION TAX
Sig vee o(Appl1 nf/ .ruactm Datc EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Nture building occupant atom or handle haaardous HEATING UNIT(T0100,0DO BN)
matertlasdefincdbythe Cupertino MuNcipal Cpde,Chaptcr9.IZ.ndthe _ Date Recei t#
Health and Safety Code Section 75537(a)7 HrATING UNIT(OVER 100,000 BTU) TOTAL•
MY. r]No
Willthe applicant or future building occupant use equipment ordevlces VFNOLATION FAN(SINGLE RESID) 1$SldAhl(T.•FiA•J'E
which emit haaatdous air cents Mount as deflnod by the Bay Area Air (:1N�EBLLP�6
Quality Management District? BOILER-COMP(3TO'OR I00,000 BTU)
1�1 Ycs �No requirements O� p 199
harthe hazer fortyC de,StlmS505undeaCha Chapter of TOILER-COMP(OVFR 100,000 BTU) N V ! Iia
the Californiaaed that If the Health Safety Code, currently
have
a tons n75534.1 f 'T
undentandthat rd ify the
ial ing occupant not a mquiyments tenant,that b mot NEW RFSIDPNTIAL MECH. SQ.f7. as{
respetolblu iss ,touance
of Rytheoate of Ocfthe requirement which rrwG be rtuM 4S ruQ Q
prim to Issuance ofaCertl(icate of Ocmpanry, H ��
Owner orauthorfmd agent Data ISSUED
TOTAL:
OFFICE COPY