21723 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification U_r 3 Qj5 PM\UTNO.
Rulldirg Address: .
21723
ane. A A
CITY OF CUPERTINO-BUILDING DIVISION 1
Lie : yPyLICATION I PERMIT _Z- q
/En enr. 'CEELECTRICAL -MLCHAMCAL CATEGORY CONTROLA
h� m QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrnc
PFRh4TISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby alflrm that lam licensed underprovBlaionsns of of Chapter9(mmmrn< APPLIANCESRE9DEMIAL JOB DFSCRII'IION
ingwitxhCSlne ll( ddf«n3ofthe Bysl a ( slonsCude,and my
License PANELS l ��� I
1/L
Date Contrador ``\J ,
ARCHITECTS DECLARATION 701-IOX)AMPS
OO 7. (understand my phns shaBbe usM apublicremrda OVER tWO AMPS SQ.FT.FLOOR AR f/SQ,F7,
u O 63
Licensed Professional SIGNSELECTRICAL /fin
6 OWNER-BUILDER DECUBATION (/�s(JY//AI
Z� J IherebyalRrmW NE exempt ER the L,aiRAder'a LI¢nx lAwlorthe 9rEC1ALCIXCUIi/MI9C -
p p� fo1lowingreason.&&1on7101.5,Businessand Prolessiona Code Anydtyor / n
Kzacy TUIP.MLTQI OR POLE(NST.
county which requires a permit tomm
rutruct,alter,improve,deolinh,or repair I/rj/!lJ/v
� � anystmdumpdortoi l rance,al mquimatheapphontforsuchpermitto POWER DEVICES
r4 (5 file a signed statement that he Is licensed pursuant to the provisions of the -
3LLO� Contrado's License Law((Zhapmr9(commencing with Section 70W)of Divi- SWIMMINGPOOLE3.ECTRIC
slon3ofthe Bual ,,d Profewlons Code)Orthat hcbexnm Ihemlromand VA U TION
S°g the basis for the alleged exemption. Any violation of Section 7m15 by any OUTLETSSWIICIIESFTXIVRES /
applicant fora permit subjects the applicant to a civil penalty of not more,than
five hundred dollen(5500). NEW RESIDENTIAL ELFLTR
f:7 Q ❑I,as owner of the property,or my employees with wages as their sole ='FT. STORIES f TYPE CONSTRUM ION
compemsatlon,wlll dothe wesk,and the structure isnot Intended or offered for a....
5 O vie net
apply to an owner
wPcofmWns Code:The ortmpdolsUcense
[�j$$ whodur such oanownerofpmpghhiseny onem oyers,p eaicxdthtand
c. ]mpro cs nts a erk tse dee or offer ifow le.pinyee, er the dtbteuch 'RFS.UNITS
Improvements sold intendneyear fcompleton If, owner-budder Ill have L,
egor-
i prommcnt beotd withlnoneyearolcomplelion,the owner-builderwlll have
m,eturdnnofpmvingthat he dm not bund or lmpmvc for purpose of salmi: QTY. PLUMBING PERMIT FEE PN
LI 1,as Owner of the property,am exclusively contracting with Ikensecl PERMIT ISSUANCE
The Commences
mnslrudthe project(Sec.]Upl toanwane Of property
The Coor improves
License or,Law dos not apply 1ct an comer of property who ALTER-DRAIN 4 VE T-WATER(EA)
builds t r Impmvse tpursua and who contracts for such p\ojem with a
❑tradmexe licensed under ee to theConMactor'a License Law. BACK FLOWPROTECT.DEVICE FEE SUMMARY
I am exempt under Sec. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
®
Owner Date RECEB'TR
WORKMAN COMPENSATION DECLARATION FP(�S PER TRAP 5CHOOLTAX Y_ N_
❑I hereby orkcn,that I have a Insurance
a c of consent of o y therm,ora RECFR'!a
MOD'LaeofWorkcn Compewuonlnsuran¢carr certllled ropy therrof bee. GAS EA,SYSTEM-t INCA OUTLETS PARKFEE Y N
Policy
ISG C.I
Polley N DING DI e
Com env \]1�+r.n.Q U.c.�c• L. CAS EI.SYSI'FM-OVER BUILDING DIVISION FENS
[Certified copy E hereby te ci
rCertlfied copy b(Ike withh the city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
city
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRW' PAID �y
COMPENSATION INSURANCESEWERSANARYSTORM EA X)OFT Date Recei tll
(This section need not be completed 9 the permit Is forone IT
hundred dollars
Qt 00)¢IewJ
I¢rtily that In the performance olthe work forwhkh this permit is issued WATER HEATER W/VENT/ELEGTR ENERGYFEE Y N—. '
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workem'CompensationlAwaol Calllornh. Date - PAID
O Z Applicant NEIN RESIDFNTTAL PLMB. SQFT. Date Re ei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemptlo,you
N should became subject to the Warken'Compensatkn pr .,=eolthe Labor TOTAL:
Code.you must forthwith comply with such provisions or this permit shall be
W > deemed revoked. _BUILDING FEB
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby affirm that there is a construction lending agency for the perform, ELECTRIC FEE
7 Z ance of the work for which this per b loved(Sec.3097,Civ.C.) TOTAL:
o O 1,nderLNar¢ ♦ /L PLUMBING FEE
i LLI" lender.Add mu, QIY.I MECHANICAL PERMIT FEE
MECHANICAL FEE
O W 1 mNlythat l have read thlsapp catlonand statethatthe above lnformatlon
ucormct.(agree rO complywlth alldtyand county oNlnances and rote laws PERMIT ISSUANCE FEES PAID: s�
} N relating to building constructlon,and hereby authorize representatives of this Z l &6Ts�L
Z City to enter upon the above-mentioned property for
trope
purposes. ALTERORADDTOMECH. Date Recel tM
V _ (We)agree to save,Indemnify an d keep harmleu the City of Cupertino P
against liabilities,Odgments,costa and expenses which t ylnany.y..ruc AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against old City In consequence Of the granting of this permit.
'/� /L- AIR IiANDWNG UNIT(OVER I4OBBCF.M7 coNsrRucnoN rax
Signatureo/App nUC o=uch or (Ate EXHAUSTHOOD(W/DUCT) CONSTRICTION TAX PA
ALLRDOUS MATER( SUISCLOSURE -r�L{�-h IN 9/ Lo 4Sd
Will the a ppllca nt or future building pant store or hand le hazardous HEATING UNIT(TO 100,000 BTT]) spate Reuel tit
materuladeflned by the Cupertino Mu rapal Cod,Chapter 9.1 7,and the -
Ileahh and Safety Code Section 75537(a)I HEATING UNIT(OVER 100,000 BM' TOTAL:
Ye n No
Will the applicant w future building Occupant use equipment or devices VENTILATION FAN 6INGLE RESID) ISSUANCE DATE
which emit haardous air contaminants as defined by the Bay Area Air
. Quality Management District? MOILER-COMP OHP OR 1WOM BTU)
4Yee ❑❑Nu
havcread the huamcusmaterials requirements under Cha pier 6.95of BOILER-COMP(OVER IO0,000BTU)
the California Health h SafetyCod,Sectlom 75505,75533 and 75SM. I FEB
understand that if the building does not ourrently,have a tenant,that it b my NEW RESIDENTIAL MECH. Ee SQ.FT LN
nsponsibillty to notify the occupant of the requirements which must be met
prior to iwwnce of a Certificate of Occupancy."
— C r ,— ,4 f
Ownerorauth dagent r Date ISSUMBY._�_)a
TOTAL:
OFFICE COPY