21678 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Project Identification PELWT NO.
Building Address: 21678 .
T Ofo
re arra: one: A S A A
S CITY OF CUPERTINO-BUILDING DIVISION NI /� C
O
Contractors Name: Lia No: APPLICATION / PERMIT
BLTLDINC-EZECTRICALPLUMBING-MMHANICAL CATEGORY COMROL p
.rchitect/Engi= Ge.No:
QTY ELECTRIC PERMIT FETE BUIL ING PERMIT INFO `
Addreax PFRMITISSUANCE ❑ ❑ r�
LICENSED CONTRACTORS DECLARATION u
Ithereby af/irtnthat lam licensed
Bunder mvChapter9(cAPlfIANCESRESIDENTAL JOB DESCRB'TION
ingwthSatoni00WofDlvsf.3oftheB.Mnss..dPm(essiomCyde.and
L m cub 11 r„<e'°°affect; 3 z G PnxELs' C. G I //YI Yf i f ��z✓��'/
Dat _e-�'j Cont ad.,
ARCHITECPSD CLARATION 101-1000 AMTS
Z (understand my playshall be used as public records.
OVER TODD AMPS SQ.FT.FLOOR AREA S/S(j.FI.
3 Oiz SIGNS ELECTRICAL
•�/tl Licensed Prefessiovl
<�u 1 here OWNER-BUILDER DECLARATION
n n SPECIAL CIRCUIT/M]SC
by Z owingrssermthatlam31,5,B fromBushe in
ess
Prractoos License Taw fort he
county hick reuirr. esa permit
construct,
anter,Improve,
by Code:Mydtyir
county which requlmapemutromvtmct,alter,lmprove,derrol4h,orrepalr TEMP.MEITR DRI'OLE(NST.
;3
V„o any atvttureprleme t that
he as aReased rersuant to the revisionsor such ofpermit e ppyyp.R DEVICES
U R4 a'signed statement that M 4 Bunged Pursuant to the provisions of the
i_
Is Contractor',License Law(Chapter9(mmrnencingwith Section 7000)of Divi- SWIMMING POOL ELECTRIC_i5 sion3ofrhe Businessand Professions Ccde)orthat hebexemptrherefromand VALUATION
the basis for the permit
sd exemption. Any vtolacivi of natty 7031$by any ,S
0 OUTI.ETSSWITCHISFUCfLRFS `/J')
-
applicant fora pemdt subject the applicant roactvil penalty o(na more than
five hundred dollars(S500). NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employeeswith wages as theirsale ES TYPE CONSTRUCTION
pensadon,will d o the work and the structure isnot intended or offered for
J C M so In(Sec 70”Bu,inev and Professions Cade:The Contnttoe,cave Law
't' does not a pply to an owner of property who Wilda or improves themes,and 01
OCC GROUP RES IINTTS
who doeasuch work himself or through h4 own employees,provided that such
Improvements are not intended oroffered fowls.If,however,thebullding or - TOTAL:
i pmvernentu,oldwlthinoneyearofmmpidiontheowner-Wdderwittheve
Ih rden of pmving N
at he Wild or improve for purpose ofsale). QTY PLUMBING PERMIT - FEE FLOODZONE AP.
Lj L as owner of the property,am exclusively contra"',with llnnsed pFRh ISSUANCE
m^tracmn to construct,the project(Sec.70K Business and Pmfeviav Code:
The Contractor's License law doe,not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild,or Improve, themon,and who cimrms, for such pi,imis with a
�gIllfattor(s)licensed pursuant to the Constrictors License Law. BACK FLOW PROTECT.DEVICE
'FEE SUMMARY
LJ I am exempt under Sec ve
B&P C for this man
Owner DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y N
—Date
WORMAN COMPENSATION DECLARATRECENT#
41 ION
[:31 hereby affirm that I have a certificate of consent to ulLmsum,ora FD.NRES PER TRA SCI{DOL TAX Y— N_RECEIPT#
certificateofWorken'CompevaHonlreurance oraurti�ropythermf(Sec. GAS EA.SYSTEM-1 LUG4 OUTLIFS pARKFEE RECFd'N _
Policy bC3 6 2
Pcllry# GAS EA.SYSTEM-0VER d(FA)
a i. (ei-a-s<� BUILDING DIVISION FEES
Certified copy baby famished.
CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�'jCeni(ied ropy b filed with the cityWpectlon division.
/Y CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE
ITNasettlon need ria tr complcted'd thehepermit
mit 4 ne(Drohundred dollars SEWER-SANITARY-STORM FA.200FT. Date RC i t#
(s100)or less.) WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
Ill not employthal any persain in any
mannerhew.rk far to lanht pesmlHs Bused, —
I shag nes employ any person In any manner as u m berome subject to the WATER SYSTEM/TREATING Workers'Compenaatlon Laws of Glifomla.Date PAID
Z ant
NOTICE
o SOTICEiOAPPLICANT:e aftermakingCo pe Certificate Exemption,you NEW RESIDENTIAL('LMB. 9Q}7, Date Revel t#
should bemrrc,vbjett ro the Workers'Conch prone b^provhiovrmit s Labor TOTAL:
N
Code,you eked.forthwith comply with such prov4iov or this permit shall be BUILDING _ C�)
i > deemed revoked.
S CONSTRUCTION LENDING AGENCY SEInDateR�eipt#
.�
Z Ihereby affirm that then is a construction lending agency for the perform, !FEES
one of the work for which this permit B Issued(Sec 309'7,Civ.G.) TOTAL:
rJ Lenders Name
!- Lenders Address QTY. MECHANICAL PERMIT ITE
J (Certify that lhave read this app0mbonand aatethatthe above Information
W bmreact I'gree to complywithall city and county ordinances and state laws PERMIT ISSUANCE
W relating to building construction,and hereby authorize representatives ofthb
Z sty to enter upon the above-rrenrbned property,fou Wpmdon purposes. ALTERORADDTOMECH.
(We)agree to save,IndemNfy an d keep harmless the City of Cupertino #against Ubilitl r}dgments,caro and expenses which sayin any wayacctue AIR HANDLING UNIT CFO 10,000 CRM) L:
against vi ty' mnsequ a the granting d this permit.
AIR HANDLING UNTr(OVER 1g0D0CFM) CONSTRUCTION TAX
Signe ApPh.rfAJ?5j,0Fxcmr _ Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTU)
material a,defined by the Cupertino Municipal Code,Chapter 9.12 and the a
I lealih and Safety Cede Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) I .1-,1
7�
❑ Yea r'N. /R �V
Will the applicant.rf"tun building occupant use equipment or devices VE [ILATIONEAN(SINGLE RFSID) s'
which emit harardou,air mntamiruna as defined by rhe Bay Area Air I 4 1
Quality Management District? BOILER-COMP OIE'OR IW,000 BTU) 1 �a
4hvemadthe haaardu materials requirements ander Chapter G95of BORER CO P(OVQIW,000BTU) �r�'r� s��/s
the California Health&Sifery Code,Sections 25505,25533 and 25534. L � �i�3?r f�(r
understand that if the budding does not comT�ly have a tenant,that it a my NEW RESIDEVFTALMECH. SQ.FT. WNs INQ u oy o€rtaRrMEttL
mpons�biliry to notify eaecv Not of the tmrrent which mu at be met n
prinrm anc<e IRmteofOccupancy. CI : Of PF,RiINQ
era or red agent Date TOTAL; ISS ':D BY:
L
OFFICE COPY