20607 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
reBuildin Project Identification PERMIT NO.
Building Add21331 s,�, , IAc1L� 20607
wmr _ A� one:
(TqL��II� CITY OF CUPERTINO-BUILDING DIVISION A -
ConlracorsNime: Lie,No: APPLICATION / PERMIT T� S 6) O
Architect/Engin«r: Lk.No:
BUILDING-E.ECTLUCA(.PLUMBING-MECFIAMCAL CATEGORY CONTROL
�O
QTN ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address T PERMIT ISSUANCE — `�'I I ',
LICENSED CONTRunder SDEons ofCION �J l/�}-
Ihereby
ectionrmtratlam Bcessedunderpressand ro Cations9de,and c- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Incense is infon fore anDlvfect. (the Budnessand PwfeWonaCode,and my
Lt.. bin full force and affect. PANES
DateClam Lk.N 0
Date Cantnctor UP TO 200AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
rc0 O I understand my plans shall be used as public records. OVER 1 W0 AMPS SQ.FT.FLOOR AREA $/SQ.FT,
(v%b Licensed Professional SIGNS ELECTRICAL
<<f OWNER-BUILDER'DECLARATION
SPECIAL CIRCUIT/MLSC
I hereby affirm that l am exempt f«m the Contranor's License Law for the
qqqqqq following reason.(Section 70315,Businessand Professions Code:Any dtyor
TEMP.MEI'FR
F countywhich requiresa permit to construct, m
alter,Improve,deollnh,orrepalr
anystmtl mpdortolb Wuanceaborequlreatheaer tto
ORPOLE[NST.'
'y , ppBcant(mauchp
S
1 file a signed statement that he is licensed pursuant to the provisions of the ROWER DEVICES
m
Ow Contractors License Law(Chapter 9(comenciog with Section 7000)ofDivi.
�OS don 3 of the Business and Prefessimu Code)or that he is exempttherefrom a nd SWIMMINGROOL ELGCCRIC yALUATION
the basis far the alleged exemption. My violation of Sectlon 7MIS by any OUTLETSSWO'CHES-FI)(TURES f B Sl% Lf
G�
applicant for a permit subjects the applicant to a civil penalty of not more than a 0
fi hundreddolhrs(SM, NEW RESIDENTIAL ELECTRSQF7. y70RIPS TYPE CONSTRUCTION
�nL as owner of the property,or my employees with wages as their sok
c
alter, 91 do the work and the structure is not Intended or offered for
ec
O
sale(S7.,Ruslness and Professions Code:The Contractors Licenu law
$ does notapplytoan owncrofpmperty who Wiklaorimproesthereon,and
EE whodmssuchworkhm lforthroughhisownemployeea,providedthat.ch OCC.GROUP RFS.UMTS
Impro vemenbre anot Intended oroffered formic.If,howev u%thebullding or TOTAL:
impmvement bsold withinoneyearofcomplction,theowner-bullderwill have
tlgr,fprrden of proving that he did not build or improve for purpose ofule.). QTy, PLUMBING PERMIT FEE ,1:)0007pNE ppN
Ll L as owner of the property,em exclusively contracting with licensed 1 PERMIT ISSUANCE ` U
The Contra ct rorewct the project(Sec.appy Business and of property
Code: .4 V
The Contractor's a the Law does not apply to an owner I property who APs-DRAIN -WATER(EM q
Wilds t r Improves thereon,and who contracts !m such p.opm with .
,Rl�actor(e)11«9 edp taantt eC m'e License Law. BACK FLOW PROTECT.DEVICE FEESUMMARY
B &P C for this reason DE FEES Lj I rt ,etF t un e S c _
3 DRAINS FLOOR ROOF,AREA,COND. D SAMTARY Y N
• Owne - Date REC=N
YOR C IAN OMPENSA 1 DECLARATION ppfSppR TRAP SCHOOLTAX Y N
❑I ere a((Irm that I have a«rtificate of consent to self-Insure,ora RECEIPT N
cenlfi t fWorken'Compe.tionlmuranworamnBiMwpythereof(Sec. GAS EA.SYSTFM-]INCA OUTLETS PARK FEE Y N
3800, C.I
Coliryk RECEGAS EA.SYSTEM-OVER DING 'Tp
Cm any BUILDING DIVISION PEGS
[�Certifled copy is herebyfurnished.the iGREASEANDUSIRL WASTE INTERCEPTOR PLANCf•IBCK PEE
�Cenlfled copy V filed with the city
ty Inspection division.
CERTIFICATE OF EX EMPTION FROM WO R KERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA 2WFT Date
(TMs stolon neednot Lr compiled lithe permit V(Drone hundred dollars
($10 WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
Icecedify dify that In the performance of the work for which this permit is issued, —
I shallnot employ any person in any runner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB._SQFT. Date Remi t#
O NOTICE TO APPLICANT:ILafier making this Certificate.(Exemption,you
should became subject to the Workers'Compenaation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be
Wj deemed revoked. BUILDING loo
CONSTRUCTION LORDING AGENCY SEISMIC FEE L
CL F3 Iherebyaffirm thatthereie a construction lending agency for the perform- s�� ELECTRIC FEE
7 Z an.of the workfor which thbpurmlt Is issued(Sac.3097,CIv.C.) TOTAL: rl W (�aS
Q0 Lenders Name oC PLUMBING FEE e r p
U. Lenders Address - QTY. MECHANICAL PERMIT FEE, MECHANICAL FEE a
OW 1«nify that l have read l his application a rd state that theabova lnformatlon
4 hemect.1 agree to complywith all city and county ordinanm and Yatelaws 1 PERMTTISSUANCE a, FEES PAID:
>. 9L to building construction, hereby authorize representatives of this '1
F Z city to enter upon the above-mentioned property for Impection purposes, ALTEt OR ADD7D MECH. 7- 00 Date Recei 1#
V Y.g.i� ai
save,Ide an d keep harmless the City of Cupertino Pmen ,cart an whkhmeyInanywyaceme AIR HANDLING UMT(TO 10,000 CFM) SUBTOTAL•
7 ence f e am gapthiopermit' ATR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Iicant/Contractor r e IXHAUS'TIIOODfW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
cant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date RCCCI 1#d by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Cade Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yen Na
Will the a ppilcant or fu re Wilding occupant use equipment or d evices VENTILATION PAN(SINGLE RESIU) ISSUAN@EIDATE
which emit hazardous air contamiruntS as defined by the Bay Arca Air
Quality Mawgement District? BOILER-OOMP C31D OR 100,IX0 BTU) N 11990
BORER
., rl Yee FaI No' t '3 .)
`('have read the haza us materials requiremenh under Chapter 6.95 o! ER-COMP(OV100,000 BTU) �f
�1 ',
the Calif, Health&Safety Code,Sections 25505,75533 and 75536.1
understantl tl the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.F1'.
caibl t o ifyth cap I"he requirements which most be rout City Cf (%'IInPT}Iprl
ore I!k e f)c panty.
Owner r rfud agent Data
TOTAL: ISSUED BY..
OFFICE COPY