21725 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruieat IdeatifiraUon 7
Bullding Address: J Y'
�T> > s s �,��� c�tii,� ����— 21725
`-713;77
ar aced: one. A A ,A
e/2 G' Q U",:, Phone
OF CUPERTINO.BUILDING DIVISION 1 ` \
ConIh
, ua.Na: APPLICATION / PERMIT
- O BUR,DINGELECTIUCALML BIND-MECHANICAL CATEGORY CONTROL N
ArcMt /Enginnr. ,Lk.No:
s / v / �'G e�✓
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
I'LL MLL
AddressIERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
' Ihercby 70thatlam licensed _3enrprprovision.
9lov7o(Chapter9(commenc
AIPIIANCESRESIDENTUg FJOB LDP�GLRR✓ROLN
Ingwlt Seetkm7000o(D3.ftheBuslesand ProfealonaCcodeandmy
Roe eI . r a effect PANELS
License Cu
-
Date Conice
erseorUP TO 2DOAMPS
ARCHITECT'S DECLARATION 2(11-1000"IS
0 CEOC I understand my plan shall be used u records.public correcords. OVER 1000 ANTI'S �.F7.FLOOR AREA $/9Q.F(.
U Licensed Professional SIGNS ELECTRICAL
<wOWNER-BUILDER DECLARATION
.P��z Ihereby afRmnthat l am exempt fromthe Contractor's Llcemalawforthe SPECIAL CIRCUIT/MISC ;;1-? 3 L�
pp following reason.C3ectien 7MI.5,Business and Profemiona Code:Any city or J /'
O Z I:,y9 TEMP.MEI'Et ORPOLE INSi. _
county which requires to construe,alter,lmprove,dennlbh,orrcpalr CC O
9�� anyetructurtprbrlolbttuance,aboraqulrcatheappnunt(msuchperMtto POWER DEVICES V O 3
ryG a-U file a signed statement that he is licensed pursuant to the provisions;of the
&05 s�n3 f heB.kne.s nd Prof mlov Codet orthathencing with
L exempethction emfmmtnd SWIMMING POOL pI.FC VALUATION
S2 the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES-FI17Al
���<5. aPPBantfora permit mb)eee theapplkanttoa tivil penalty ofnct morcthan �� O b,.�
F $ five hundred dollars 05500.
❑I,as owner of the NEW RESIDENTIAL EL TYPECONSTRLGTION
property,or my employees with wages r thele dole
compenvtlon,wlll Bothe work and the structure h not Intended or offered for
�0 vie lsec.7044,BuslnnsaM l4ofcssiov Cade:Th Comraeols Llcove Law
( $ does not apply to an owner of property who builds or Improves thereat,and
=$^ whodovsuchworkh4 lforthraughhlsownemployces,providedthtasch OCC.GROIIP RES flNTIS
impmverecra.rc not lntendeelmoffered forsale.IL however,thebulldleg er TOTAL aaaaaaaa1
Improvement hsold within oneyearofcompletlon,the owner-builderwlll have -rel
th burdeo of proving that he did not bund or Improve for purpose of sale.). QTY. 'PLUMBING PERMIT FEE FLOOD ZONE APN
U 4 as owner of the property,am exclusively contracting with licensed
contractors to construe the p.jd(Sec.7044L Busine»ard Professions Code PFRNIFT MUANCE
The
m n
Contractor's Ltmnse Law dot apply to an owner of property who ALTER-DRAIN&VFNI'-WATER(EA)Wilds or Improves thereon, and who ca.uacta fee such projects with a
&orW licensed pursuant to the Contractor's License Law. FEE SUMMARY
I am exempt under See. B 15A P C for this rcFEES
Owner Date ma BACK FLOW PROTECT,DEVICE n DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
• RECEII N
WORKMANCOMPENSATIONDECLARATTON FIXTURES.I'ER'IRAIs SCHOOL TAX Y N_
❑1 hereby affirm that I have o certificate of consent to self-inaurc,ora RECERsT N
c M,I-abo(Worknrs'Compevatlonlvurance oracertlf4d copythem5f 6ec. GAS EA.SYSTEM-1 INC.401.171= PARK FEE Y N
Polk lab CJ
Pollry N GAS EA.SYSTEM-OVER 4(FA) RECERT N
Com aId w�ort0 P(.C�l NIIILDINGDIVISIONPEES
'�Ceny nified mpybhereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANGI-IEGK FEE
®Certified!copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE
(I'hkiiedton need rat W completed if the permit Is foram hundred dollars SEWER-SANITARY-STORMEA.2(XIT. Date Remi t# S, d
($lao)on
I certlythess. h)t the performance of the work forwhkh this permit is bwNWAiERHE,T'FRW/VEN.T./E•rC.TR ENERGYFEE Y
t
, —
N
I shall not employ any person In any manner se as m become subject to the WA=SYSTEM/TREATING
worker Compevatlon laws of CalBomh. Date PAID
O Z Applicant N1WRESIDENTIALP[MB. SQ.FT. Date Recd t#
t Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become sub}ct to the Worker'Compensation provisions of the Labor TOTAL:
CC j deemed revoked.Cade,you most forthwith comply with such provisions or this permit shall be
W BUILDING FEE -Q D
1
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Ihercbyafflrm that them is a construction lending agency for the perform ELECTRIC FEE
Z anceoftheworkiorwhlchthbperactb et! 3097,CIv.Q TOTAL e�
LL 4 lender:Namsca
e PLUMBING FEE
LL !- Lnnderb Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O,
O O orred.Iagrehavaraply with
all
ty and county
ordinanceshat the ndformation
(L bctingt Iagrceto complywlth alncityabyauth ore preesand date of this PERMIT ISSUANCE FEES
} relto ating ongmhe above-on,anddpropetyarimrcectionpurposo/fhb �,hH5G
F Z cityWenteree to ave,indemnify and
property far Inspection purposes. ALTER OR ADDTD MECH.
_ (We)agree m cave,Indemnity an d keep harmiea the City of Cupertino a[C RCCCI(lt#
agalvtlhblllties,judgments,comeand expenses which muy In anywayaccrue AIR IANDIINGUNIT(T'010,000CFM) SUBTOTAL'
ago Wt vid City to con sequence of the at,fhb permit.
AIR HANDLING UNIT(OVER 14"C17M) CONSTRUCTION TAX s—
Signature ofAppllon Contraear 1Xste EXHAUST ]GOD(W/DUCT) C-O"N5TRUCTION TAX PAID:
HAZAR DOUS MATERIALS CLOSURE J,i1 Cg56_
Will the a ppllo at orfumrn building occupant store or hand le hazardous HEATING UNIT(TO 1 W,()[10 BN) 1-1-1 ReCei t#
materhl as defined by the Cupertino Munldpal Code,Chapter 9.l$and the -
Id Safety Code,Sectt000 iion=(.)7 HEATING UNIT 100, BTU) TOTAL:
❑YeaS,P
Will the applicant or❑future building occupant use equipment or devices VExRLATTON FAN(SINGLE RESID) ISSUANCE DATE
which emit havnlous air e.m.m aants as defined by the Bay Area Air
Ouality Management District? BORER-COMP OHPOR 100,OW BTU) tJ
Ye" II:�11 No R'
have read the hazardous materials requlrcocnb under Chapter 1.95 of BOILER COMP(OVEt IDg0W BN) r
the GBfomia health k Safety Code,Sections 25505,25533 and 25534.1 f L6 1 1991
understand that if the building does not currently have a tenant,that it b my NEWRESIDENTIALMECH. SQ-Fr
responsibility to actlfy the occupant of the requirements which must be met ,
Prior to issuance ofa rtifiota ofOnv anry Parris--
Owner or aumoriz<a. nt• Data ISSUED BY:
1 TOTAL:
OFFICE COPY