21061 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
On tidies Pmeat Identification ILl"T NO.
Bu11d1Rg Add;4_
o�S�' v R - - 21061
care am�e:+ one. A
�y CITY OF CUPERTINO-BUILDING DIVISION
Contractors me: LIc.No: APPLICATION I PERMIT
s BNLDING-ELECTWCALPLUMBING-MFGHAMCAL CATECK)RY CONTROL N
Architect/aglneer. Llc.No:
QTY ELECTRIC PERM Ff FEE BUILDING PERMIT INFO
Addreu
PERMITISSUANCE - ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I ithSyi-n7Olhatlam.i.3 fth.B.prov..d ofChapteCodc acorn APPLIANCESRESIDENTIAL J08 DESCRIPTION
Ingw iSect1on7000)of d offe on3o(the Buelnessand ProfesslonsCade,and my
license le In s (o cad lcf If PANELS
Llnnse m LIeM
Date
CO
BcUP TO 200AhU
CHI S RA 701-IODDAMPS -
��qquu oto O I understand my plans shall be u as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
FnZ Limned Professional SIGNSELECTRICAL
z�6OWNER-BUILDER DECLARATION
Iherebyaffirm that lam exempt(romthe Cenamorb Unca.Law for the SPFGIALCEtCU1T/M
following reason.(Section 70315,Business and Professions Code:Any city or
F f' county which main hes a permit to mnbact,alter,Improve,demolish,or repair TEMP.METEt OR EI
any structure prior to its Issuance,also requires the applicant forsuch permR to POWER DEVICE
Ne a signed statement that he V licensed pursuant to the provision of the
Ow Contndors License Law(Chapter 9(mmmencing with Section 7000)a(Divi.
ffF...�OS ai.n3.fthe B.s ...dPrfe.W.CWe)arthat hebexempttherefromand SWIMMI GR70L CUOCC
A�yT�ION
the basis for the alleged exemption, Any violation of Section 70315 by anyOUTLETS TC applicant fore permit subjectatheapplicanttoa civil penalty of net nnrethan c-'C1Ove hundred dollars($500). SQ FTI,as owner of the property,or my emptayeee with wges as thetr rule NEWRISI A ECTRTYPECON5fRllCTION
mmpenation,will clothe work and thestnc oro,is not Intended or offered forO ssIa(See7044,Bu.1reeaand Pmf.dmuCde:ThsContradorsLice.Lawdoes not apply to an owner of property who Wilds or Improve.thereon,and RFS,UNITS
WW who doessuch work himself orthrough his own employees,provided thatauch
improvements are not intended orof(ered forule.If,however,(hebuilding or TOTAL:
improvement untold within oneyearofcompletlon,theownarvbu0derwlllhave
tlgjZurden of proving that he did rwt build or Improve for purpose ofeale.). QTY, PLUMBING PERMIT FEE
u FIAOD TONE APN
4 as owner of the property,am exclusively Business
and
with lammed PFRMITISSUANCE
contractors ct construct Lt..the project(Seo 70 apply
to ness end Profession Code:
The Contractor's Limns.law don not apply tct an owner of property who ALTER-DRAIN&VENT-WATER(EA)
coltia or Improves thereon,and who mncnab far im such pl,ojem with a
ryR{lactor(sexem licensed
under
to the Contractor's Llnnx Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec B &P C for this reaaan
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Date RFLI]Ff N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have• i..,.le of consent to pythe of or RECEIPT N
certiflnteo(Workers'Compenatlonlnuranre ora mrtifled ropythercof(Sec. GAS EA.SYSTEM-1 ING4OUILETS - PARK FEE Y N
Polis Lab CJ
Collry M RECEGAS F.A.SYSTEM-OVER 4(EA) DING DI N
Cm any famished. BUILDING DIVISION FEES
❑p adtfldifiedm )' filed
th the cid. CREASE/NDUSRI,WASTE INTERCEPTOR PLANCHECK FEE
ertTOed copy V llkd with the city Inspection divisors.
' CERTIFICATE OF O(EMPTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE
(This.edlon need not be completed lftheperme
it lsforne hundred dollars $EWER-SANITARY•STORM EA.70)FT. Date Revel t#
($100)orhad.) - WATER HEATER W/VENT/[LFL'1'R ENERGY FEE Y N
I rertify that In the performanm o(thework forwhlch this permit I.issued, —
I shall not employ any person In any manner an,n to become subject to the WATER SYSTEM/TREATING
Wmkara Compen.tion Laws of Callfomla.Data PAID
O Z Applicant NEW RESIDENTIAL PLMB, SOFT. Date Recei t#
Z Q NOTICE TO MPLICANT:IL after making this Certificate c(Ex.mptlon,you
F should became subject n
to the Worker$Compeatlon provlslonsofthe Labor TOTAL:
W Code,you=at forthwith comply with such provision or this permit shall be
2
>' deemed revoked. BUILDIN
WG
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mntroctlon lending agency for the perform
ELECTRIC FEE
Z an m ofthe work for which this permit is annual(Sec.3097,Civ.C.) TOTAL:
LL O LandAdde PLUMBING FEE
LLE lancerres Address 4rv. MECHANICAL PERMIT FEE MECHANICAL FEE
O W mct.Ia t I reet.c compmad ly
with allcitynand dcounte that the yarditunces aid gatela s
1 broingtobgrteto complywith andyandmuntyors representatives
and eesoftwe PERMIT ISSUANCE PEES PAID:
} N relating to Wlldingro bov con,and dpropetyorinrepresenpurposo(this
lee Z d toe upon the abovcmentloned property(or Inspection purposes. ALTPR OR ADD TO MECH.
(W a c to save,Ind=fy an d keep harmless the City of Cupertino Date Rotel t#
V aga U.1, tles,pdBecame,msis and expenses which may In anywayacnue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
a t. Cityinro ofthegraml ofthl e IL
_ AIR HANDLING UNIT(OVER 10,(I00CFM) CONSTRUCTION TAX
not roof Applicent/Contractor Date E%HAWT HOOD(w/DucD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfunrc building eccupertsiore or handle haranlous HEATING UNIT(TO 100,000 BTU) Date Recei t#
mandalaadefined the upertlno Munldpal Code,Chapter 9.17,and the -
I❑alt ad Safety Neon 75537(1)7 HEATING UNIT(OVER 100,000 BTO TOTAL:
Y.Will the applicant or no building occupant use equipment or devices VENTILATION FAN(SINGLE RESIU) ISSUANCE DATE
which emit harar,dousai mntaminantsaa defined by the Bay Area Air
Quality Mange 1D'trict7 BOILER-COMP DI-0'DR 100,IXD BTU) � �
4Yes Na
M1ave read the haxar smiedalsrequimr ntsunderChapter6.95of BOILFR-COMP(OVEL 100,000 BTU)
the C.Ifomia 1lealth&SifetyCode,Section 15505,75533 and 75534.1
understand that if the building does not currently have.tarsal,that It is my NEW RESIDENTIAL MECH. SQ.FT. S ° N T ],-590rsspanib y notify the occupant of the requirements which must be reset •L
prior kc�elsaitjabacxf.CxrtIflc4tccdO7pamy.
ner or tit orired agent Date ISSUEDDYOf('uRp�IH$ ve..
'TOTAL:
OFFICE COPY