21443 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
—Building Protea Identification PERMIT NO.
Building Address: 21443
77I
neva G: `� �! yyG—=Phone:
f f CITY OF CUPERTINO-BUILDING DIVISION I1 1
Contradm'.Name: LIcAft .No: APPLICATION / PERMIT 6l,
ULt/i✓L�'L BUILDING-aE RICAIPLUMBING-MECHANICAL CAITGORY CONTROL#
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PIIIRMITISSUANCE ❑
LICENSED COemwd under
pr DECLARATION
I hereby Busiestannsof Chapter ssions9(rommen APPLIANCLSRESIDENTAL JOB DESCRIPTION
iI...1 i cion force of DlWfect. ofthe Businessand Profeaslon.Cole,and my
License
Is In(uB force dna erred. PANELS �L-+_ _S•.au,�a
License CWm LM.# f �J�/G--
Oate Contractor UP TO 200AMPSI-W t�0
ARCHITEe usedDECLARATION OVER
030 AMP"'
cc0 2 I understand my phra e W I W used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
z❑Oq
U Licensed Professional SIGNS ELECTRICAL
"N OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC - ^
zf, � Iherebya(flrm thatI am exempt from the Contractor'.License Law for the
QQ (oeowing...($action 7031.5,Business and Predestine.Code:Any city or
i"'u7 county which requlrsea permit tomrokuct,alter,improve,demolish,orrepair TEMP.MEM OR POLE INST.
y 7 anystructure pdorto Its Issuance,also requlrestheappllcant forsuch permit to POWER DEVICES
rN1 y file a signed statement that he Is limeaed pursuant to the provisions of the
Ow(� Contractor's License Low(Chapter 9(cernmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
15OJ slon3ofthe Business and Pro(emne
loCode)orthat he Isexempttherefromand
'77 the Wats for the alleged exemption. Any violation of Section 7031.5 by any RR /
appU.ekfor a permit subban
the a ppilcant to a civil penalty of net more t n OUTLETSSWITC}{ESEXTURFS
five 1,as o nerdolof the p0). NEW RFSIDFM[AL ELECIAP_SQ,FT. STORIES TITS CONSTRUCTION
I,ea owner lido t property,or my employees with waged their sole
compensation,Business andhe Pr end rsaimstrode:Th Commmeot intended or rows d forLaw 1// u
5 ❑ sale(Sec. pply to Businessand
prepeloro Code:The or fimpaora Llcewe Law
$ docs not apply to an owner of property who builds or Improves thereon and OCC.GROUP RIS.[NITS
C: whoaoementsa nhimselfedorough Msowne,If,hoeevertdedthaI A
improvements am not Intended oro(fercd forwle,ILhowevegthe bull �(Qr ' I TOTAL:
improvement hsold withinoneyearofcumplation,the owner-bullderwllTh ve -t
t rden ofproving that he did not build orimprove lorpurpmeo(sal.s� QTY, l q LUMBIIV PE IT °� FEE [:IppD ZONE APN
1.as owner of the property,am exclusively contracting with BcenosdeBE
ntracton to construct the project(Sm 70K Business and professionsC t PERMIT ISSU
Contraaoe.License Lw does not apply to an owner of property wFo /J A
fids or Improve.thereon, and who contracts for such pwiects with a ALTER-D 4s VENT-WATER(EM
actor(a)licensed pursuant to the Contr ct.e.License Law. p FEE SUMMARY
I am exem t under Sec. B k P C for this means BACK FLOW OTECT.DEVICE
Owner I l..�.. Date � DRAINS.FLOOR ROOF,Aa YCOND. SANITARY RECEIPT
WORKMA COMPENSATIONDECLARATIO P0('NRES PER TRAP SCI;OOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,ora RECE T#
certificate of WorkerYCompmuatlonlnsurance ora certified copy thereo((Sec.
380011,0C.) GAS F.A.SY -T ING.4 DUTLETS PARK FEE Y N
PolCo Policy GAB-FA.SY rERd(EAI RECEIPT J,
MY BUILDING DI VISION FEES
C.hifiedcopyIn 6fil hereby tumished. GREASEANDU L WASTE INTERCEPTOR PLANCHECK FEE
MCertltled copy Is(fled with the city InepMian divlalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP FAIR
COMPENSATION INSURANCE SEWEtSANITARY-STORMEA 20017 Date Recei [#
(this section roadnd W completed If the permit Is forona hundred dollars
(f100)ftifytJ WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
(certify that emin ploy
anyhe arson i any m neerworso se to rahTs s,subjrmitect
c Issued, -
I Whale not employ any person In any manner Wo u to become aub�ect to the WATER SYSTEWTREATING
Workas'Compensatlon Laws of Gll(ornh.Data PAID
—
Z Z Applicant
homes, NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
O NOnCE licant APPLICANT.If,akar making this Certificate o(Exemptlon,you
F should bee subject to the Workers'Compensation provIsiom of the Labor TOTAL:
Ln Code,you=at forthwith comply with such provlslorm orthls Ferrell shall he
]' deemed revoked. BUILDING FEL
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a com uctlon lendingagency(or the perform ELECTRIC FEE
Z ante of the work for which this permit Is tasued&c.3097,Civ.C.) TOTAL:
V O Lender'.Nave PLUMBING FEB
LL F Larder's Addreaa QTY. MECHANICAL PERMIT FE
E MECHANICAL FEE
O W I mAilythat l haverealthts application and auto that theaboveinformation �` l
0. facetted.lagreemcomplywlthallcityandcountyordlnance.and state laws PERMIT ISSUANCE db FEESPAID:
>. N relating to building conetmotion,and hereby authorize representatives of this
[— Z city to enter upon the above-mentionedER
property for Impection purposes. ALTORADDTOMECH. Date R('.Cel [#
V _ (We)agree tont ,Indemnify an d keep harmless the City of Cupertino
against llabllitles' gmenre,meta and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: i
agaiwtaald ronsequ nre o(thc gr intlegefthlsperenit.
/ �y`9 AIR HANDLING UNIT(OVER IaW0CFM) CONSTRUCTION TAX
tgnatum of Applicant/Contmetor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) -
materialasdefinedbytheCupertinoMuNcipalCode,Chapter 9,1 Z and the Date Reuel t#
Health and Safety Cade Section 25537 W 7 HEATING UNIT(OVER 100,00D BTU) TOTAL: .
❑ Y. No
Wllltheapplieset or mmbuiidingoaupantumequipmentardevims VENTILATION FAN(SINGLE REED) SUANCE DATE
'which emit harardous air contaminants as deflned by the Bay Area Air Pill V��,fyf/�
uta lily Management DlsMa7 BOILER-COMP AFB'OR l00,OW BTU) Q
1 v. No
have read Healthe h
fcty Code,ls Scions underChapter 2S54.I of BOILER-IbMP(OVIIIR 100,000 BTIn �� S �O
the
ersta dt Health building
Safety Code,cut
currently
75505,ve a toad 25534.1
understand thatlithe tify the occupant of to requirmnts which
that It is mybe
NEW RESIDENTIAL M(ECFI. SQ.FTresp .
prior Ie160Ryto of.Ceheoc to ofOttherequimmentawhich must be-met � F( 1M
prior to Issuance o/a Certificate ofOmpancy. ^^'''�j'R7f'�� RR--pp.�-� '�II��'�� ��� aa��
Owner or autharized agent _ Data ISSUED B :*]jpW1�V•�•QCl
TOTAL: .�
OFFICE COPY