21352 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
0uEding Address: P4RhBTN21.352
caner a
I 11'- S '- `I CITY OF CUPERTINO-BUILDING DIVISION
cant ora me: Lim.No: APPLICATION /PERMIT
T -tcCATEGORY CONTROL X
BUILDING-ELECTRICA4I'LUMBING-MFLIiAMCAL,
A ited/Engineer. Lic.No:
QTY ' ELECTRIC PERMIT• -fig,^ ' 'BUILDINC_PERMIT•INFO
Address: - PERMITISSUANCE•.. , ❑- ❑ .❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirmih.tlamllcenvedunderpr"iona.f Chapter9(mm mi, APPLIANCES RESIDENTIAL )OB DFSCRBTION
I ngwith Secdon 7000)of Divbdr m 3 ofthe Bfe
uslneasand ProealonsCode,and ery
• license Is In 71}ftrpeyynd effect. ^ PANELS
LIre nseClass(a'ti`7 LicY tY ti� ,o1111(I • ..ep�9ie
Data'7.;iCantnctor �� I ✓(�J (J/^ UP TO 200 AMPS
ARCHITECTS DECLARATION 201-1ODO"PS
q�q�uu NO ZZ l understand my plans shall be used as public records OVER 1000 AMPS SQ.PL FLOOR AREA $/ .iT,
Licensed Professional - SIGNS ELECTRICAL
I"n 6 EL7 OWNER-BUILDER DECLARATION SPECL1LCRiCUIT/MISC
1hereby affirm that l am exempt from the Contractor'.License Law for the
O fallowing reason.(Section 70315,Business and Professions Code:Any city or -
PM countywhlchrequimsaper ttomnatruMt iter,lmpmvgde=l6h,ormpair SMP.M ETER OR POLE INST.
fanrourc
yatdprior to lte bsuance,algia requlrestheappllcant(.,such permitto
O flee a signed statement that he Is licensed pursuant to the provlsiom of the POWER DEVICES
Cmood.rs License law(Chapter9(canurencingwlthSection 7000)ofDlvi- SWPMNG oOEELECTRC
Bion 3 of the Business and Professlom Code).,that he la exempt therefromand
the Weis for the alleged exemption. Any violation of Section 7031.5 by any VALUATION
f 'apphcantfor a permit subjects the applicant to a civil penalty of not more than OUT LE7SSWITCHFSFIXTURES
five hundred calls.Ck%0). NEW RESIDENTIAL ELECTR
F1I,as owner of the property,or my employees with wages as their sole SQ.FL _5 RI M TYTYPE CONSTRUCTION
compensation,willdo the work andthestrudure unot intended or offered for . .
O sale(Sec.7004 Business and Professions Code:The Contradors Llceme Law
does not apply to an owner of property who Wilds or Improves t hereon,and .. '
G who does such work himself or through his own employees,provided that each OCC.GROUI' —TES.UNHS ',
Improvements are not intended or offered far sale.If,homent,the build ing in TOTAL: - - -
Improvement is sold within one year ofcompldlon,the Owner-builderwlll have
tl�uN
cn of proving that he did notbuild orimproveforpurposeo/saes.). QTY,' S PLIIMBING*ERMIT FEE; �' p500DZONE APN
LJ I,as owner of the property,am exclusively mntradlng with licensed PERMITISSUANCE
-
cantraciom to comtmd the project(5C,.7044,Business and Professiamd Code:
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) -
Wild,or Improves thereon,and who contracts (or such ptujeats with a
ro,➢![adorte)Ilrensed pursuant to the Contractors Lirenae Law. BACK FLOW PROTECT.DEVICE. FEE SUMMARY
LJ I am exempt under,Sec. B k P C far this mason
Owner Date DRAINS FLOOR,ROOT,AREA,COND. SANITARY Y NrMIT �
WOR KM AN COMPENSATION DECLARATION - RECE'TIt
ly]I hereby affirm that I have a artiflmte of convent to self-Insure,or a FIXTURE"`PER 7RN' SCHOOL TA% Y - N
ateo(Workers'Compemationlmuranmo acertlfiedmpythereo((Sec. - RECEIPT
3800,Lab C.) �y GAS EA.SYSlE9at-1 INCAOUTLETS PARK FIT :Y_'N_
Policy M_�.VC./�l L)�e��J - RECEB'1'M
Co,a.y GAS FA.SYSTEM-OVER4(RA)py Ls hereby furnished. ' _ BUILDING DIVISION FEES
ertified copy is filed with the city Inspection dhr,ftn. GREASE/INDUSTRLWASIT.INTFRCEPTOR PLANCHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION h parmaNCG SEWER SANITARY STORM EA 200FT Date ReceI ted
(Thlswctlon need not be
COMPENSATION
If the permit LCE one hundred tlollan
($1 OO)o,lessJ Is WATER HEATER W/VENT/ELFJ= ENERGY FEE Y. N
I rent thatothe person In any
so as,to lt became
permit1.s leaned, —
I shall not employ any person In any manner w as to become mbjed to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
O Z Applicant - '
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FE Date Remi toy
should became subject to the Woricami Compasatlon provlsimd ofthe Labor TOTAL: y
CC Code, with each Pvl. orthle permitshall be G pS Od
LU M roim
mBUILDING> deemed revoked. LDI— � ..
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a co,dtroctlon lending agency for the perform. ELECTRIC FEE
Z once ofthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
O Lenders Name • - • . PLUMBING FEE
ly t- Lend.e.Addres QTY. ",'MECHANICAL PERMIT FEE MECHANICAL PEE
OU Icertify dealt lavcm.dthlaxppliationand state that the.lamm Information - -
W is correct.I agree to comply with a 11 city and county ordinances and slate laws PERMIT ISSUANCE.d PAID
} U) relating to bulldingcarutrunion,and hereby authorize representatives o(thts '
F Z city to enter upon the above-mentioned property for lmpreion Purposes. ALTERORADDTOMECH.
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
again ilitiesJudgments,coetsandexper. Ichmayleanywayamme AIR HANDLING UNIT(TO 10,OOOCFM) SUBTOTAL:
against,. City consequenceo( ant g fthl.pennit. -
AIRHANDLING UNIT(OVER 10,000CrM) CONSTRUCTION TAX
Sign tore of Applicant/Contracmr
Data IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMA ERIALSDISCLOSURE --- -
WilltheappBantorfutumbulldingoccupantatore.,handle haeadous HEATING UNIT(TO 100,ODO BTU) Date material as dented by the��VVpertlno Municipal Code,Chapter 9.I2,and the Reeei t#
Plaalth and Safety Cc on 75532(a)i IIFATING UNIT(OVER 100,0(0 BTU) TOTAL:,
Yes RNa - - _
Will the applicant or tutu building occupant ave equipment or devices VENTILATION FAN(SINGLERESID) IS�{JAIdC DATE
which emit havrdous It Rami®n r&p1ned by the Bay Area Air n *Qf§
• Qu lily Management od7 BOILER-COMP QHP OR 100,0(111 BTU)
4haveYee Na FEB `Z2 1991
read theh materials requirements under Chapter G95 of BOILER-COMP(OVER 100,D00 BTU)
the California Health h Safety Code,Sodium 25505,25533 and 2534.1
undanda d that i(the building d a nal currently have.tenant,that it is my NEWRESIDFNTLALMECH. SQ.f.7
rsspo 'bl ty to notilytheoccupant oflhoc ircmentswhich most bemet ,WO�aaf/$U�yno
priopt Lss ante (a CaCIf ey�� d d[ W W {i 1.3- `
Owner or authnzed agent a� Date - ISSUEDil (I
TOTAL: —
OFFICE COPY .