21759 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hoilifing Project Identification PIi TNO,
B �Address: 21759
caner ante: �^ one: 1
COUL� CITY OF CUPERTINO-BUILDING DIVISION _
Codpa .Na e: (�, Lk.N. APPLICATION / PERMIT
z l IL D BU(LDINC-ELECTMCAL-PLUMBINC-MECF( LAICAL CATEGORY CONTRO N
4
Architect/Engineer. Lk.No:
�—
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add,e,. PFRMITISSUANCE ❑ F-1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(comment, APPLIANCESRESIDENTTAL JOB D65 RIPIION
ingwlth Sedion7000)of Dlvielon3ofthe BusloessanciPro(esalone Code,and my
license 1.1.s effect.Lt. C- ? PANELS ( r x
Date Clam Con r ` l
Date Contractor
ARCHITECTS DECLARATION 201-IMO AMPS )241
X
0 Z I understand my plans shall be used u public records. OVER 1000 AMPS SQ.FT.FLOOR ARG
O
Licensed professional SIGNSELECTRIGL
6 OWNER-BUILDE0.DECLARATION SPECIALCIXCUIT/MISC
IherebyafOrm that l am exempt fronthe Contractors License Law for the
oo
O followingreason.(Sectlon7031 S,Businessand Professions Cy
ode:Mdtyor
Z s:
county which requires pertNtmcoro/run,alter,Improve,demolkh,ormpalr TEMP.METIER OR POLE INST.
anystruclure prlorto Its Issuance,then requirestheapplicant forsuch permit to POWER DEVICES
ilk a signed statement that he Is licensed pursuant to the provisions of the
3a, Contractors License Law(Chapter9(mmmeneing with Section 7")of Divi- UAIQN
Off^ slon3otthe Business and Prefeast mCodOmthat he lsxe
empttherefromand SWIMMING POOL ELECTRIC VALTO
O the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWTTCHESFIXTUR S
S�GW75]
five
fora permit aubjecte the applicant to a civil penalty of not more than (�
five hundrednerofdollars thepro NEW RESIDENTIAL ELECTR SQFI. STORIES TYPE CONSTRUCTION
campeiv�n ❑I,asowneroftheproperty,ormy employeeswithintwagesas rtheledole
Ic&c.H44,B..dothe work,and thestroctureh not intended o ioffered for
O sae(Sec apply to alnow and f property
rope ty Code:The C improves License law
3� docs notapplysuch ork owner offprough hisoWilds orimprovnlhereoMand uch OCC.GROUP RIS.UNITS
who odoes
ments ace nethimselfIntended
orough hisownemployees,provided the building i or
improvements mprelokthhoweveg deerlI have TOTAL:
Improvement Issaldwlthlnoneycarotcompletlon,lheawner-W Ilderwill have
thrq*rden of proving that he did not build or Improve for purpose ofsale.), - QTY; PLUMBING PERMIT FEE h10OD TONE APN
U L as owner of the prop",am exclusively contracting with licensed pp RISSUANCE
rontracton to corewct the project(Sec.703ly Business and Protessloru Code:
The Contactors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improve
thereon, and who contracts for such pLojecta with a
cq¢(ffactor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L-JI am exempt under Sec. B k P C for this reason BACKFLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS FLOOR ROOF,AREA,GOND. —
,�� I
WORKMAN COMPENSATION DECLARATION
RECFIPTN
❑I hereby affirm that I have a wrtl0cate of consent to se161nsure,or a FIXTURES PER TRAP SCHOOL TAX Y N
mdifimteafWorkers Compereatlonlmun moramAifed ropythereof(Sec. RECEIPTM
3800,Lab C.) GAS G.SYSTEM-1 INC4 OUTLETS PARK FEE Y_ N
Policy N RECEIPT It
Com any GAS EA.SYSTEM-OVER 4(EA) BUI LDING DIVISI ON FR BS
ECertified copy It hereby te
E3 Certified copy Is(Teed withh the city
inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREISETRAP PAID
Cor Wcom
COMPENSATION INSURANCE SEWEILSAMTARY-STORM EA.20OPT. Date RCCCI t#
(This section need nal W completed lithe permit Is(Drone hundred dollars
(SI00)orleaa.) WATER HEATER W/VEM/E.FCTR ENERGY FEE Y N
I rectify that In the performance of the work for which this permit is Issued, —
I that 11 not employ any person In any manner sa as to become subject to the WATER SYSTEM/1REA77NG
Workers Com anon Laws Ica De PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr, Date Revel t#
Z NOTICE TO LICANT:$after making{{ L .ertificateof Exemption,you
sh.ld become subject m she Workers'Coutltlon provIslom of the Labor TOTAL:
N Code,youmustforthwithcomplywitheuchp.W loruorthhpermitehallbe
j aeemedrenaked. BUILDING `•E ✓)
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebya(Nrmthat there is a contraction lending agency for the perform - TOTAL: ELECTRIC FEE
Z ance of the work for which this permit is beend(Sec.3097,Civ,C.)
V O Lender's Name PLUMBING FEE
U. enaeraAaaresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW Icedlfythatl have madthle applicationand statethattheab°ve Information -
(L Is correct.I agree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEESPAID:
} @e relating to building construction,and hereby authorrepresntatives of this
W
H Z city to enter upon the above-mentioned property for mapeclon purpose. ALTERORADDTOMECH. Date Revel t#
z (We)agree to save,Indemnify an d keep harmless the City of Cu pert no
against liabilities,j-dgTefilltasquit and expre.which may In any way.¢rue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a I IdCi enc oft anting at this permit /_ AIR HANDLING UNCI(OVER l0,000CIM) CONSTRUCTION TAX
tfV 2 T
Sigmture o(AppIcent/Contras Date IXl-IAISIHOOD(W/DI1C'U CONSTRUCTION TAX PAID:
HA7ARDOU T occupant
DISCLOSURE
Will the defined
lore future Cupertino
gompanbtare hhand9.hazardous IiEATINC DMT(IO tOD,000 BI1n Date RCCCI t#
material as Safety by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Satiety coder�Section 25532(x)7 BEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea LTJ No
Wlll rent hamrd usaruo contaminants
occupant by the
or devices VENTTGTION FAN 6INGLE I(FSID) 1966L1/dP_&DATE
which emit ham aNcontaminantsas defined by the Bay Area Air rfyliV
Quality Management DlsMct7 BOILER-COMP ptB'OR 100,O(q BTU)
4 Ye, 4"° ,ION 2 41981
have mad the & nus mater,Se requirements 5533 and
of � BOILER-COMP(OVER 100,000 BM
the Calift at lith buildinghe Safety Code,Sections 25505,ve a t and 25534. I
understand poresithality to n tifythdoes of t emq.1moced.w which
that it is my NEW RESIDENTIAL MECIi. SQ.FT
pnortoissuacenot ifytheiate of oftherequircmentawhich must be met Isl�aa wi ApeseN►r�
prior to issuance ofaCectiflcate o(Ompancy. MV �r�YW4
Owner or authorized agent Date ISSUEDBY: oUv
TOTAL: —
OFFICE COPY �''