21827 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identificati n PUMTNO.
Building Address 21827
v Uig CITY OF CUPERTINO-BUILDING DIVISION 2 r �,^Q
°nlract0r.Name: Lk.N.: APPLICATION /PERMIT 6 Lt
BUILDINGELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL N
• Architect/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:' PERMITISSUANCE ELM
LICENSED CONTRACTOR'S DECLARATION
Ihereby ton7OODthat fDimhomard,1 .3.fthunder Chapter 9 Code, menc APPLIANCFSRE9DENTUL JOB DESCRII'ITON
IkerssISIS fon force of Dlvfect. (the BukneseandPro(eskonaCode,and my `
Ikenm Is ie full force and effect. PANELS
License Clam Lk.N
Data Contractor UP TO 200AhMS
ARCHITECT'S DECLARATION 211-IODOAMPS
µppµ!!aO Zp l understand my plain shag be umd as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA f/SQ.Fr.
Licensed Professional SIGNS ELECTRICAL '
<6 OWNER-BUILDER DECLARATION
rn'a SPECIALCIRCU1T/MISC
7 S,of Ihereby afRrmthat I am exempt from the Contractor's Llrense Law for the
following reason,(Section 7031.5,Business and Professions Code:Any city or
Ft'u9cntywhichrequlrevapermktommtmo,alter,fmpmve,demlbh,orrepair
4 T P•METCR ORPOLE INST.
1006
� anystromme pnLss
ortoits uance,alk,requirestheapplicant forsuch perrofir
PJ TNG 0 S file a signed Statement that he islicensed pursuant to the provlsla s of the POWER DEVICES
3wt�, Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
g O si.n3.friss Buknemend ProfessbruCode)orthat he la exam therc(romand �17V C 9
I�Q� the basis far the alleged exemption. Any violation of Section 703x5 by any OUTI.ETSSWITCHES-I'l ES \ �v 1 4/'�
pGpW51j appBnnt fora permltsubj tethe applicanttoacivil penalty&SM nnrethan J CM
five hundred dollars($500). STORIES TYPECONSTRUCTION
'9..' 521,as owner of the property,or my employees with wages as their Sole NEW RLSIDENITAL ELECTR
compensation,wBldothe work,and thestructure isnot Intended or offered for
Ocols(Sac.7004 BusNess and Profemloru Code:The Contractors Llcerue Law a r
$$ does not apply to an owner of property who Wilds or Improves thereon and OCC.GROUT' RES.UNITS
whodoessuchworkhimself orthrough hisownemployees,provided thatsuch
Improvements are not Intended proffered for sale.7L however,thebullding or 'OTAL:
improvement bsold within o.eyear.fcomplmbNtheowner-W Bderwlll have
tF�urden of proving that he did not bund or improve for purpose of sate.). QTY PLUMBING PERMIT FEE FLOOD ZI APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 1�1
contractors to construct the project(Sec.7014,Busine...d Professkms Code: L Ji
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improveson
there ,and who contracts for such pTojeb with a
exsw
"bactor(s)IkenaM pursuant to the Contractor's License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
L�I am exempt under Sec. B k P C for this reason
DRAINS.FLOOR ROOP,AREA,COND. SANITARY Y N�
Owner Dale RECEIPTS
WORNAtANCOMPENSAT10NDECLARATION pD(NpES PER TRAP
SCl1OOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-insure,or a `� R[:CC®Pf M
certifiate of Workers'Compensation Insurance or a unified mpy thereof(Sec. GAS EA.SYSTUI-t WG.4 OUTLETS PARK
MOD,Lab C.) ITB: Y_ N
Policy N GAS PA.SYSTEhr-OVER 4(EA) RECEIPT'N
m BUILDING DIVISION FEES
Certified copy Vhereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCI-IECK PGE
❑ fled mpy 0 filed with the city Irapa Hon division.
CERTIFICATE OF O(LMITION FROM WORKERS' GREASE TRAP PAID
INSURANCE D
(This Section nred not WENSAIf NpermitESEWER-SANITARY-STORM EA.
furors XIOFT. at,
Reoait6lLF,
(St00)orle that
WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
Illnotfify mat in the person In any
mahe nner
forwhkb copeesubtcis 0o the
I shall not employ any person In any manner m m to become subpct to the ' WATER SYSTEM/TREATING
Workcre'Compenmtlon Laws o(Gllfornla.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB._SQET. Date Recei Nl
O NOTICE TO APPLICANT-.U,after making this Carificateof Exemption,you
HShould become Subject to the Workers'Comperuation provisioss.fthe Labor TOTAL:
N Cade,you moat forthwith comply with such provisions or this permit shall be
y dermad revoked. - BUILDING EE l
IL IL CCONSTRUCTION LENDING AGENCY SEISMIC FEE
M -Z I hereby affirm that there is a comtmmon lending agency for the perform TOTAL: ELECTRIC FEE
ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
U O fender's Name PLUMBING FEE 70-06
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 111
Imnlfy that l have re ad thbapplicatbnand Z.thetheabove Information Z C)C7
C iscomoct.lag,m to comply with all cityand coortymollnanms and state laws PERMIT ISSUANCE ('Tf7 FEES PAID:
relating to building construction,and hereby authorize representatives ofthls
Zcity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH, a� Date Reeei f#
_ (We)agree b cove,Indemnity an d keep hamiless the City of Cupertino - P
against liabilities,pcigments,mks and expenses which may In anyway accrue AIR HANDLING UNIT(r010,ODO CFM) SUBTOTAL:
against said City In consayuence of the granting of this permit.
a —fl-/�� O Eq—?,f AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
Ig atureo pplin�/Contractor Date//C�ono-actor C' a' Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha nolle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCei Ip
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
I Icallh and Safety Code Section 2M32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL-
❑Yea M No
Will dw.pplicant.,future building occupant use equipment or devices VFNIVATION PAN(SINGLERESID) SSUA �E DATE
which snot hazardous air contaminants as defined by the Bay Area Air NNL� �1 `
. W Iity Management District? BOILER-COMP DHPDRI(p,OfD BTUI (C1 /� ,
4Yes j�No l 66
havereadtheh..gusmkerlalsrequtmmnreund,,Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the Glifrnia Health&Safety Code,Sections 25505,25533 and 75534. I j AswovNtM!
understand that if the building does not currently have a tenant,that it is my NEWR®DENTTALMECH. SQJT. eft
responsibility to notify the occupant of the requirements which must be met
prior to issuance ofa Gstiffcateof Occupancy.
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY
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