21054 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect ldentmcatlon PERMITNO.
Building Address: /�v O U f OAC. ✓ V ' 21054
neva antre:,� ,` Cl foyne�:
�--I WFw s Z —L't� CITY OF CUPERTINO-BUILDING DIVISION
• Contractors Name: LIc.No APPLICATION I PERMIT ((
BUILDINGE,ECTRICA4PLIIMBING-MECHANICAL CATEGORY CONTROL N
Ar hltect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
'with Se ion rd 70Matl am Bceruefthunder R.i ssb. Pa f.iot.0(cormnene- APPLIANCESRESIDENTIAL ]OB DESCRIPTION
Ingwse 1,1.loll force of d effeon3o(the Buelraeeand Pro/mloneCode,and my
license la In full force and effect. PANELS
License Chse LIc.M l 1
Date Contractor UP TO 2DO AM
ARCHITECTS DECLARATION 201-1000 AMPS
art ZD I understand my plaru shall he dead ss public records. OVER 1000 AMPS SQ,FT.FLOOR AREA $/SQ.FT.
Licensed Profemlorul SIGNS RLECTRICAL
2.
�< OWNER-BUILDER DECLARATION S
z Ihembyaffirmthatlamexempt fromthe Contractor's License Law fm the SPEC LCIRCUIT/hi LSC
02-q❑❑ (ollowing reason.(Setion 70715,Buslnm and Professions Code:My, tyor
-A
F" county which requima permit meenstmt,alter,Improve,demolish, rr�Pair P.METIX OR TOLE INSf.
anystrurture priorto its Issuance,alsorcquires theappllnnt for uch p r tto
O file a signed statement that he U licensed pursuant to the provisions f he WER DEVICES
SOSContractor's License Law(Chapter9(mmmencingwith Section y ) I.
sion3oflhe Buainenand ProfmlonsCode)o thathelsexemm retro NC POOL ELECTRIC VALUATION
Soo the basis for the alleged exemption. Any A tion of Section i Y O ETSSWITCHESEXNRFS co
O� applicant fora permit subjects the applicant to vilpemltydn n
five hundred dolhrs($SM. RESIDENTIAL ELECT,
❑1, a owner of the property,or my emplo es with wag Irsole —SQ.I7. STORIES TYPE CONSTRUCTION
C�6 compensation,will dothe work andthestructur isnot into d raffen,
D sale(Sea 7011,Business and Professions Code: Con o Llow
L8 don not apply to an owner of property whobul ori nthc a d
FS^ whodocuchwork hlmUorthrough Msown a Ioy rovldedt M OCC.GROUP RFS.UMTS
un
Improvements are not Intended oroffered form . , vegthebull gor TOTAL: (W
improvcmenthsoldwithlnoneyearofcompletlogt ner-builderwillhave
rdenof pmvingthathedldnotbulldorlmp ve for purpose of sale.). UMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am excluaiv ntrating with llcen
retractors to construct the project(See 701 rand ProfmWtu IT ISSUANCE r.y;
Coral Improves
es the law dm rat apply ct f owner p props TER-DRAIN VENT-WATER(EA)
Wild.or Improves thereon, and who contracts for such p(o w
cq➢ITator(s)Boomed pursuanttothe Coruractori License Law, CIC FIAWPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for 1 le aso t FITS
DRAINS FLOOR ROOF,AREA,COND. --- SANITARY Y N'
• Owner Date RECEPTN
WORKMAN COMPENSATION DECLARATION Fp(TURFS PER TRAP SCHOOL TAX Y N
QI hereby affirm 1k,-that 1 have a IdxdOna of consent to opythure,ora ^� RECD.N
3800,Sated(Worken'Comperuatlonlwuranco ora ce0,kd ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS 2�W PARK FEE Y N
3800,Ieb CJ
Pdllry N
any GAS F.A.SYSTEM-OVER 6(EA) RECEIPT
T N
CmCfed copy V hereby furnished. BUILDING DIV
ISION 17EES
MCimi,ed mpy V(fled witlethe anyIrepectlon division. WASTEINTERCEPTOR PLANCHBCK FEE
CERTIFICATE OF UEMPTION FROM WORKERS' GRFASETRAP PAID
CN becom
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,200FT. Date Remi t#
Rhla aectlon need net be complied If the permit V(Drone hundred dollen
(5100)erlm.) WATERHFATERW/VENT/E.FCTR ENERGY FEE Y N
Imrtify that performance !su
the performance of the work forwhich this permit Is ed,
[shall not employ any person In any manner n as to become ubjM to the WATER SYSTEM/.TREATING
Workers Compensation hwsof California. Data PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQ,FT. DatC RCcel t#
Z O NOTICE TO MPLICANT:If,after making this Certificate o(Hxemp[lon,you
Hshould become subject to the WorkersCompensation provisions of the Labor TOTAL:
W Code,you at forthwith comply wi/hnuch provisions or this permit shall be
1 doomed revoked. BUILDING FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL 1 hembyaffi0nthat there is a censtutlon lending agency for the perfo0ry I(k ELECTRIC FEE aQ$
Z anm uTOTAL:of the work for which this permit is Ised(Sec.3097,Civ.C.) .(�
C) O Lender.NamePLUMBING FEE L#
LLF' Lender'sAddms QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerti/ythatl have read thlsapplloeon and stalethatthe above Information
fl bmrret.tagreetocomplywltha,cttyandcountyordinanmsend Yatelaws PERMIT ISSUANCE FEES PAID:
} U) relating to building construction,ami hereby authorlu representatives of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADD70MECH. Date RCCCI t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilitka,jodgmente,conte and expenses which may in anywayamme AIR HANDLING UNIT(TO 11IM0 CFM) SUBTOTAL'
age Wt dcitym con once It sating ofthls permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Ig naw o pplinnt/ ontratrn Dat DaLAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
of
or future building occupant store or handle hazardous HEATING UNIT(10100,00011I11)
materialasdeflned by the Cupertino Municipal Code,Chapter 9.12,andthe Date RCCCI t#
Ilealthand SafelyC c Ion25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
7 Yee No
Wditheappllnnt r rebuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardo air contaminants as defined by the Bay Arca Air
silty MawgemIin Dis 7 BOILER-COMP pFm OR 100,IXD BTU)
4
Y. o PAID
have read the h_n� rods maleriab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 0�
the California Ileal &Safety Codx Sect1om25505,25533 and 25534. 1
understandthat ebulldbg don not mrrcntly have atenant,that It b,my NEW RESIDENTIAL MECH. SQ.FT. SEP ,0990
responsibility to ratify the..pant of the requirements uiremes which must be met
Pit or anm o/a Ifkatettoidpancy, sN��.'r
not
(horiud agent Dn� "SUED BY
TOTAL:
OFFICE COPY