21876 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed identification PERMIT NO.
Building Addma-I ;MZ�OG 5 G Pro 1- � 21876
I
9 dale: Nom• One: AFFLICA riON-
CITY OF CUPERTINO-BUILDING DIVISION
°^°r' Lk. APPLICATION it PERMIT -�
Ofijoll BUILDINGELECTRICAL-PLUMBINGMECIiAMCAL CATEGORY CONT L N
Ar i ct/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
PERMITISSUANCE ❑' ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provislond of Chapter 9(mmmenc- APPLIANCESRESIDENfIAL JOB DESCIMIUN
Infn 7000)of an3o(Ihe BudncuandProteuloniCe, nd my
license 1.1.full to d effect
PANELS
LlrenChu 0-19
/•N
•A//t
Date tactor (jUP TO 200 AbTS
ARCHITECTS DE15LAICNTION 201-IMO AMPS
q�q�vv at I understand my phruehall be used u public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
00
k (Cj Licensed Professional SIGNS ELECTRICAL '
< OWNER•BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Z '3 Theraowing reason.
that I Secrist7 exempt fromthe d Professio Lkense Law fort he -W 7ER
County g reason.(Section permit
5, o Business and Otto,Improve, Code:Any city or
� � cwntywhich rcqulreaa permittoconstroct, Improve,demolish,orrepalr TGMP.METIR OR POLE
.aa anystm=mpAortolts ance,shoeequlmtheappUri tforauchper tla POWER DEVICES
108�V file a signed statement that he is Bernard pursuant to the provisions of the q/
ITE
3O� Contractor's License Law(Chapter9(mmnlendogwlth Section 7000)of Divi- SWIMMING POOL ELECTII
Mon 3ofthe Businessand Profeulom Code orthat hats exampttherefromand VALUATION
g ydthe MM s for the alleged exemption. Any violation of Section 70315 by any
Q applicant fora permit subjects the applicant to a civil penalty a not more than OUTLET SWITCHES-FIXTURES �zJJtJWr��W
(Iva]],..hundred hepr. NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCT ION
�e ot owner of lbs property,or my employees with wage as thele dole �'�'
C Z a mmpenulon,Business ul Paoand the dmde:Th Cmuraot ndedo License
d for
Law
'S ❑ sale(Sec 7044,Business and f property ho builds
or imp doth License Law
does not apply loan owner ofthroug his onemporimprwvidedes that
ryuch OCC.GROUP RES.UNITS
wand
hodoes nu a ark telfedorough his own le.It o e,providedlhalagor
Improvementsarenmintended earofc d(olein.ILh ner-p ilderwdingve TOTAL
Improvementbmld within oneyearo(compldlon,eMowner-bullderwlli have
t Men of proving that Mdid not build or Improve for purpose of ale.). QTY. :PLUMBING PERMIT FEE WAODZONF APN
n Las owner of the property,am exclusively contracting with licensed
mmractorstomrulruct the project(Sec.7044,Bualneuarta ProfessionsCode: PERMIT ISSUANCE f'7
The Contractor.License Law does na apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) 1'�
bullda or Improves thereon,and who contracts for such pgojects with a
cna-4)BM
cenxd pursuant to the Contractor's License Law. FEE SUMARY
am exempt under Sec B A,INP C for this rem BAIX FLOW PROTECT.DEVICE OUYSI OF,FEES
av
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEITT N
WORKMAN COMPENSATION DECLARATION pD(gvpFS PER TRAP � SCHOOL TAX Y N
❑I hereby affirm m
that I have a rdfials of consent to elGinsum,ora R—
certitlate of Workera'Compensatlonlnsurance ora certltled copy thereof(Sm. GAS EA.SYSTEM-I INCAOUILECS
3800,Lab J PARK PBE Y_ N_
Policy GAS F.A.SYSTEM-OVER 4(FA) RECEIPT N
C°'^ ^Y BUILDING DI VISION FETES
Certified copy d hereby furnished. GRGASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city Inspection division,
CERTIFICATE OF IXEM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Rewi t#
(I'hlssedion need next Mm
copleted I(tM permit U(Drone hundred dollars
(5100)orfy that WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I snot that emIn ploy
anyhe performanceoninan ?mannerhe weak for which hews permit b hated, —
I shake not employ any person In any manner w ns to become subject toted WATER SYSTI M/TREATING
Workers Compensation Uwe o(GII(ornia. Date PAID
C• Z Applicant NBWRESIDFNDALMMB. SQ.IT. Dale Recei l#
-Z NOTICEild co esubjeAM:H,akarmt'Comecutionaking I his powercate of Exemption,you
H sh de,
most
subject co Warmish Comprowloss orthlopermitns;of all be TOTAL:
� N Cotla,you nwet(orthwlth comply with each provisions or this permit shall be
> deemed revoked. BUILDING �CaO
W CONSTRUCTION INDWG AGENCY SEISMIC FEE t
CL aof th wolent?Mltherclsemmiruction Isissud(Sec.3 garry 7,Cia. .) perform ELECTRIC FEE
Lin
D Z sof the work for which this perMtia Luted(Sec.3097,CIv.CJ TOTAL:
(o-) 2 refer.Name PLUMBING FEE
LL l— ender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 mrtlfythatl have read this appliestion..d AnhEhattheaboveintormatlon
.tmrrcct.I'greetocomplywlthallcityerdmuntyoMlnan.sand date laws PERMIT ISSUANCE FEES PAID--
>.
M relating tobullding mmtrudlon,and hereby aulhomm raprcsentatives ofthis
H
?Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDRJMECH.
(We)egrce to e,Indemni harmle he City of Cupertino Date RCCe1Fa[#
(.I ag.has 1,lllt ,tadgmanl sande sees nu nywayarems AIR HANDLING UNIT(TO 10,(0)CFM) SUBTOTAL:
.gal ai ity lam en a ted it AIRHANDUNG UNIT(OVER IO,ODOCI•'M) CONSTRUCTION TAX
�6
Ignaturcof AppBant/Contractor I Date EXHAUST t100D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIRtheappliant or future building ocmpantstoreor handle hazardous HEATINGUMT(TOIOO,ODOBTUE Date Revel t#
materialas defined by the Cupertino Municipal Code,Chapter 9.1 and the
Ilexlth and Safety Code Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: O
Yes MN. •
Will the applicant or future building°ccupant use equipment or devices VENTILATION FAN tSINGLF.RESIDE ISSUANCE DATE
which emit hada Mous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DEEP OR 100,00 BTU)
(-1 Yes No
N haveread the hazaQ ous materials requirementstnder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the GllfrniaHealth&Safety Code,Sections 25505,25533 and 2:534.] (d Cl] q � I�E1�
understand that if the building don wb not menlly have a tenant,that it my NEWRESIDENTIALMECH. Ff. I-LV Ce / J
responsibility to net By the occupa rat of the requ lmments which must be met
prior to Issuance of a Carl]Hate of Occupancy. ANY
I
of AIIMe}InR
Owner or authorized agent Date ISSUED BY—
btaF}faJj Nay ice.•'
OFFICE COPY