21389 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proert Identification PERMIT NO.
Building Address:
102,11 Dr 21389.
11�"�`rrj �j72 A 710(0 CITY OF CUPERTINO-BUILDING DIVISION ` (Y ON o A
C n o'aNa yj_�J/mj APPLICATION 1 PERMIT
�� " 'd'S�1n Y(•1 •L/ BUILDING-ELDCMCAUML BINr—MFLHAMCAL CATEGORY CONTROL M
Architect/Enginmr. � Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERh9TISSUANCE ❑ ❑ ❑
LIC tNEEDhat I a CONTRACTOR'S DECLARATION
Ihereby
uction7000)o hviscens oftheB knessaon.of Cssions9(commme- APPLIANCFSRF.SIDENTfAL JOB DFSCRErfION
Ingwlth in
offs n3 ofthe Buelnnaand ProfessioneCodc,and my
Ilmn.le in(u o rad effect. PANELS
License ass LI[.R 03s l7 1 LMA (- .
Date Contractor n r 201-1000 AMTS
ARCHITECTS DECLARATION
N I understand my poreshall be used as public record& OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ.Fr.
O
�
� Llmnsed Pro(emlorel SIGNSELECTRICAL
..I
.4 OWNER-BUILDER DECLARATION SPECIAL CER ULT/ ISC f
p., I herebyafilrm that am exempt from the Contractors Limn.Law for the
zP1q`2 � following minion.(Suction 7031.5,Business and Pm(essions Code:Any city or TEMP.METE -
APOLE INST.0co hrcmdto provbh,arrepalr
yotmctmprortoltsWaneaharequimstheappBmntforsuch RPOWEDEVICESOne
G
a algned Moment that he la Iimnsed pursuant to the provisions of the
3µ Contractor's License law(Chapter9(commencing with Section 7000)g'jDlv- a -1 t "
OI'n (tinrt� if SWIMh9NG[SOL ELECTRIC
Sslon3ofthe Butlnemand Pmfewiom Code)orthatheise.mpttherc anti, / VALUATION
the basis for the alleged exemption.Any A I tion of Section 7flltrb lr
applicant fora permit subjects the applicant to a civ 11 penalty of�di airs tahP�,n C OUTLEISSW[ HESF1XIl1RE5� coo five hundred dollar($500). \./ \ n l —L
F NEW RESIDENTI LELYY:TR SQ.FT. STORIES IWE CONSTRUCTION
G ❑e s owner ll the property,or my employees is act
with wages r theirrs� 1
7�
compensation,wllldothe work andthe etructurcbno[intended or of(emd(bi
does Am O sale(Sec.7ply to owner
of property
Code The Wilds orimporms License law
�$ whodoamuch roan ownerofprough hisonemorlmproovided thereon,and uch OCC.GROUT' RFS.UNITS �
EE wprovemuch am not Intended through hlsowne.If,
h providedthat
gor
Improvements are not Intended proffered formic.th however,the buildingorTOTAL:
Improvement bsold withinoneyearo(camplellon,theowner-bullderwlll have
the burden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD WNE APN
n 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profs mint,Code:
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(F V
Wilds or Imp mms thereon,and who contra for such projects with e
gqRRtt��actor(s)licensed pursuant to the Contractor's Lima.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
cl_JI am exempt under Sec. B&P C for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have a cert]mn of consent d spythaure,ora RECEIPT M
certificate of Workers'CompereaHwireurance ora certified copy thereof(Sec. GAB,F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polis Lab CJ
Policy N RECEIPT p
Com an CAS EA.SYSTEM-OVER 4(EA)
CY BUILDING DI VISION Fr.ES
CertlOed copy la hereby tumCREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE-
❑Certified copy Ls flied with theecity
ty Irupectlon dlvlaion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.HIOF- Date Rete] ted
(Thls.ctlon need not W completed If the permit V(or one hundred dollars
($100)orle WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
Imrtlfyl a1 the pertormanceofihework forwhkhthia permitbre Issued, —
I shall note y any n In any.manner eo t be bled to the WATER SYSTIM/TREATING PAID
-
kers Co o to w of Cxfiomla.Dale
O Z NOTICE NEW RESIDENTIAL PLMB._SQIT. Date Recei Hf
Z O NOTICE TO PLIC L Aer rs'Co this Certificate of Exemption,you
ahouldounea out a orkera'Campe vex l ..rthl prep he Labor TOTAL:
~ W Carroud mocked.
forthwith pay with each provlalore orthb pemNt shall be
� > seemed revnkaa. RUILDINC PEE
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirm that them is a conatructlon lending agency forthe perform ELECTRICFEE
:3Z armof the workfo'r which this permit is Issued(&c.3097,CIv.C.) TOTAL:
U O Lender's Name PLUMBING FEE
LL Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW ImrtlfythaH have read this epplicatlonand stats that the above Information
1 bmrrect.I agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEESPAID:
7• relating to building construction,and hereby authorize representatives ofthb
Zcity to enter upon the abovearentloned property for inspection purposes. ALTERORADDTOMECH. Date Rotel [N
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino p
against liabilities,judgments,mats and express.which may In any wayacerue AIR HANDLING UNIT(TO I0,0D0 CFM) SUBTOTAL:
against said City In consequence of the grant Ing of this permit.
AIR HANDLING UNIT(OVER 10,(DO CFM) CONSTRUCTION TAX
Sigmtu re of AppOmnt/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappOmnt or future bulldingoccupant store or handle hazardous HEATINGUNIT(TO100,000BTJ)
material as defined by the Cupertino Municipal Cade,Chapter 9.12 and the _ Date Recel of
I kalth and Safety Code Seaion25533(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: bt50
❑ Yes �]No
Will the applicant or future building occupant use equipment mdevices VENTILATIONFAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air T• {�a
Quality Managcrreet D❑istrict? BOILER-COMP DHPOR 100,000 BTU) A`a!�YCd
4 Yes N No
t�uaom
ehaza omaterials requimmenMunderChapter6.95of BOILGR-COMP(OVER 100,DD0BTll) �t�oY � 51Qy�
ealth&Saf Code,Sectiom 25505,25533 and 255M. I V
if the build SCIta not currently have atenanL that it is my NEW RESIDEMIAL MECH. - SQFf
nalfythc.pantofthenquimnentswhichmustbemet
ofa cateofOccupancy, 141
lax age t ateO
TOTAL: ISSUED BY:.
OFFICE COPY