21615 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prued ldemlfication PFRMITNO.
Building Address: 21615
7y7RF_1_.Kx. one:
ALS` YR1.� ZrrjZ, 3 CITY OF CUPERTINO•BUILDINGDIVISION
t� CntraRryj^d ra-N 1 LIc.Na APPLICATION /PERMIT
. INC . BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY C0J119L1j.11�/
Anattect/Englneer.� Lt.,No: p Ira
1. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE 1.2.DQ D�r � (�I
LICENSED CONTRACTOR'S DECLARATION
Iherebyeffirnthd lamhecnsed under provisl....fChapter9(mmmen APPLIANCMIESIDENTIAL JOB DESCRIPTION
ingwllh Section 7000)of Dlvldon3 ofthe Budnessand Prefessks aCede,and my
U...le In full force and effect. PANELS
Llmnse Ciao Lic.N
Data Contractor
ARCHITECTS DECLARATION 2°1'1000 AMPS
ZO I understand my plare.hall be used es public mord. OVER 1000 AMPS SQ.Fr.FLOOR S/SQ.FT.
hi o Licenced Professional SIGNSELECTRICAL
<<` OWNER-BUILDER DECLARATION SI'FLIALCEiCUIT/MLSC f-A / T
Z Ihe.byafflrmtham
atlexemptf..the Cont.dur'.LicenseLawforthe
following reason.(Section78715,Businee.and Profession.Code:Any city or
FmuntywhichrequlresapertNttommtmMalter,impmve,demoWh,arrepair �P'MEM OR POLE INST. JT R
'`� 3 anystmmmpdortolhimame,ahomqubestheappliuntforsuchpermitlo
file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
O u.� Contractor's License Lw(Chapter9(rommencingwlth Section 7000)ofDivi.
gds don3o(the Bueineuand Profession Code)orlhd hehexempttherefromand
SWIMMING POOL ELECTRIC SWIMMINGVA'a�y�ATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any3DI / •Doc , 1�l '�
n� applicant fora permit.ubjects the applicant to a civil penalty of nor nitre than OUTLE7SSWITCIIFSFI%7URES 1 V {a
five hundred della.(9500).
NEW RESIDENTIAL ELECTR
�n ❑1,..owner of the property,or my employees with wag.as there axle �'�' STORl6 TYPE CONSTRUCTION
csk tion,Business
the work,and ionstudure h not Intended or License
for
M sale(Be.(Sec appy to snow and f property
Code:The Contractor.Lienor,law
S$ woanotapply worn owner o(proughhisoWilds morimpmovidedthat and - OCC.GROUP RES.umr
who docssuch anti amrkMmtendedlf hrough his own employee.,provided thabuch
improvement is sold ithindneyearffeedpldio ILhawevegtheerwilI have TOTAL: _DD
Improvement hsrldwithin oneyearofcomplefirn,theowner-bulMerw111 have
tfLkarden of proving that he dal not Wild or Improve for purpose of ask.). QTY. PLUMBING PERMIT FEE FLOOD7DNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 70K Business and Professlom Code: D
The Contractors License law done not apply to an..or of property who
Wild. or Improves thereon, dALTER-DRAIN h VENT WATER(EA) (�Dn, and who contracts for such p lejes with a �•
Cqa�tTa0 (s)It...itp...set to the Contractors Lima.Law. BACK PLOW PROTECTDEVICE FEE SUMMARY
u I em exempt under Sec. 0 k P C for this reason reon —
DRAINS. G, FI
FLOORROOF,ARCOD. SANITARY Y
EFErS
Owner Date NRFGF71rT N
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP )) SCHOOL TAX Y N
❑[hereby affirm that I have a ttrtlBnte of consent to self-Insure,ora �C•D 1 RECEIPT M
certlllcateofWorkeri Cam neationlmuranceoncertlfled copythereo!(Sec. GAS-EASYSTF7d1 WC4OUILEFS PARK FTE Y N
3ROQLab C.) /J
Polirya I� Z�D AECEB'fM
Com an GAS.FA.SYST MOVER 4(FA)
� Y / I BUILDING DIVISION FEES
Certtfled co yh hereby urnbhed, GREASEANDUSTRL WASTE INTERCEPTOR PLANCFIECK FEE
((Cent copyh(ikd with thecity Irupecilon dividon.
CERTIFICATE OF EKEMITION FROM WORKERS' CREASE TRAP PAID t�[�
COMPENSATION INSURANCE. SEWER-SANITARY-STORM EA.2001+1'. Date Recei t 14G%
(This section need not be completed If the permit h for om hundred dolls.
($100)orlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I eartify that In the perfmcrar ceo(the week forwhlch this permit Is blued,
I.hall not employ any person In any crooner n as to become subject to the WATER SYSTCM/TRFA77NG
Workers'Compensation Laws of California. Date PAID
z Z NOTICApplicaE
NEW RESIDENTIAL PLMB. :OFT. Date Recei t� fJ�'NS
Z O NOTICETO sub)oAM:IL after Workers'
pe Certificate of ExempteLabo
Code,shoulyou been.=at
surthwitck co plywit Compensation provhis permitof s Labor TOTAL:
Uj W Coda youmuet(arthwlth comply with such provisions or this permit shall be
> deemed invoked. L k
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE 3. _
Iherebya(flrmthat there h a construction lending agency for the perform- ELECTRIC FEE ,pd
7 Z ance of the workfor which this permit h hseed(See.3097,Civ.C.) TOTAL: b�BO
C) O Lenders Name PLUMBING FEE
( . a6
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE •�C
O W Icedilythatl have read thhappheation and slatethat the above Information
1 ordinances l agreeto comply with all city and county ordinaneand date laws I PERMIT ISSUANCE ,Z.l1� FEES PAID:
} relating tobulldingroastrudio d authorlu representatives of this
F Z city to enter upon the abo otic property for lnepedlon purpoma. ALTERORADD'TOMECH. -UD. Date Recei tp
V — (We)agree to ssv mol and keep harrdess the City of Cupertino P
againsthabWth;' nh, A...dexpenenwhichnuyinanywayacerue AIR HANDLING UNIT QO 10,000 CFM) SUBTOTAL
agaWt u'! nm the this permit.
Y 6� AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signaof Aunt/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
I HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date_ Recei tic
I lealth and Safety Code Sectlon25532(a)7 HEATING UNIT(OVER 100,D00 STU) TOTAL: D
❑Yn No
ill the
appllcantar tura Wildlngocupant usecqulpment ordevices VO-MIATION FAN(SINGLE RESID) (SSjJp JhJ(�+ITA•TE
which emit hazardous air contaminants se defined by the Bay Area At, I9'7�ki(iDD
(� Dun Ilty Management District? BOILER-COMP MIT OR 100,IX3 BTU) B��FY •FA
gYes 2oNo {ltYAl
have ad teeth& rue materials bslons 2rrenhundernd 2554.1 of ROfLER-COMP(DVIBt 100,000 BTI!)
the Crstand a Health f the building
Code, otcow 25505,have
a t and 75536.I
understand that notify the occupant
of
enultlyhavt.which that It met NEW RESIDENTIAL MECH. SQ.FT
prior
noissue
s e m of a Certificate
i c to of of the requlmmenta which most be met p(M a.•4 Mau`a'l�in'®
priorto Issuance o(a Cedlflnle of Occupancy.
(Tuner or authorized agent Date �t ISSUEDBY: fAn.. J
TOTAL: •Qy
OFFICE COPY
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