21438 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
BuildingAddress: 21438
nera on p p
x — e CITY OF CUPERTINO-BUILDING DIVISION p
Cont a 'a Name: Lic.No APPLICATION /PERMIT
BUILDING-ELECTRICALMUMBING-MECHANICAL CATEGORY CONTROL It
Ar .uect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A PERMITISSUANCEEl 1:1ElSED CONTRACTOR'SCLARATION
[hereby LICENaffirm that l am licensed under provisions of Chapor9(commenc. APPLIANCESRESIDENTIAL J08 DFSC ON
ingwith5 dion70fA)afDivision3ofthe Businessand ProfessiomsCe ,andmy
license is in fu8 once and d(eR. PANELS
License Class Llc.p 6.:-eAfV—
Date Contractor- die
ARCHITECPS DECLARATION MI-1000 AMPS
�'Z I understand my plans shall be used as public records M
OVER1000AP5 SQ.FT.FLOOR AR $/SQ.FT.
ZOGF
V Licensed Professional SIGNSELECTRICAL
661 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/11192 "
7 p,vrl, I hereby affirm that Iam exempt from the Contractor's License Law for the
pp following reason.(Section O 7(01.5,Business and Professions Code:Any city or L H TEMP.METER OR POLE[NST.
�� � cauntywhich rcqulresa pemdtto coretruct,alter,lmpmve,demolbh,orrepair
g anystructure pkorto its issuance,also requiresthe applicamtfor such permit to ]OWER DEVICES
ES Ole a signed statement that he is licensed pursuant to the provisions of the
�O w Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
Oa sion3ofthe Businessand Professiorn Code)urthatheisexemptthercfromand VALUATION
•c the basis for the alleged exemption. Any violation of Sectlon 7031.5 by any
m ,pplicantfora permit subjects the applicant to a civil peaaltyofnottnorethan OUTLET'SSWITCHFSHXTURFS
five hundred dollars he pro. NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
7 ❑I,as owner of the property,or my employees with wages r their sole �'FT
compensation,Business and
and the s Code:The
or offered for
p sale(Sec.apply
to an ow and Professions Code:The or improves
toes License Law
docs not apply to an owner of property who builds or improves 1M1ereoq and OCC.CROUP RFS.UNITS
whodoes ntsach nrffitselfedorough ffehisowale.If oweprovidedthatsuch
Improvementsarenotintendedproffered pleioe.If,ho nev Hder ldingoe AL:
Improvement bsold wLLhinoneyearofcompldion,theowner-W Rderw8l have
th rden of proving that he did not build Or improve for purpose ofsale.). QTY. PLUMBING PERMIT ELOOD ZANE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the Project(Sec.7614,Business and Professions Code.
The Contractor's License Law does not apply to an owner of Property who ALTER-DRAIN&VENT-WAM(EA)
Wilds or improves thereon,and who contracts for such p(opcts with a
cc Iactor(s)Itomsed pursuant to the Contracture License Law. gpQ((pLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B&P C for this reason
Date DRAINS FLOOR ROOF,AREA,COND. SANITARY _ Y_ N
Owner RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
ereby affirm that I have o l rt rare of consent m opytneure,ora RECEBrr N
rtlficateofWorken'Compersatlon]naurance oracertified ropythereof(Sec. GAS F.A.SYSTEM-11NC,4OUTLEI$
Polic38My
C3 aS9^O ? D3 PARK FEE Y_ N_
Com any Y GAS EA.SYS1`FM-OVER4 MAI BUILDING UI VISION FEES
� It
Cekifled copy b herebytumecityhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�ekifed copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAF, PAID
COMPENSATION INSURANCE
(Thissectionneed not becompletediflhe permit isforonehundreddollare SEINER-SANITARY-STORM EA.200FT. Date Recei t#
(s100)orlese.) WATER HFAq�W/VENT/ELECTR ENERGYFEE Y N
[certify employ
an person in of thework for s to,become
Issued,the
I shall not employ any person in any manner m ss to become subjttt[u the
O Applicant
ompensatlon Laws o(Glifomla.Date WATER sysTTM/TRFAnNc PAID
PF NEW RESIDENTIAL PLMB.
Z 0 NOTICE become
PLICANT:e ager rs'Co pe Ction provisions
o(Exemptie Labor
SQFL Date Recei t#
should became subject to the Workers'Comperoation provisimrs of the Labor TOTAL:
V3 Code,You=at forthwith comply with such provisions or this permit shall be
W > deemed revoked. BUILDING FEE
IL O CONSTRUCTION LENDING AGENCY SEISMIC FEE .c,n
[hereby affirm that there b a construction lending agency forthe perform- SEISMIC
EEE O✓
Z ante ofthework for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: ' wT r
V 0 Icridera Name U(/ PLUMBING FEE
LL 1— Lenders address QTY. MECHANICAL PERMIT FEE
O W Icekifythatlhavereadthisapplicatlomandstatethat theaboveinformation MECHANICAL FEE
S iscor,ect.l agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE PEES PAID:
} W relatingto building onex"ction,and hereby authorize representatives of this
1— Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDIOMECH.
(We)agree to save,indemnify an d keep baroness the City of Cupertino Date Receipt#
against liabilities,judgments,costsand expenses which may In anyway accrue AIR HANDLING UNIT HO 10,W0 CFM) SUBTOTAL:
zgaind,oild City i/n�5qnsequenm of the granting of this permit.
( sicca /JZ , /_/D_C/ AIR HANDLING UNIF(OVER 10,000 CFM) CONSTRUCTION TAX
Signature mf Applicant/ o actor 7Date EXHAUST HOOD(W/DUCT) CONSTRUCTION—TAX PAID:
HAZAR OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTT;)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
Health and Safety Code Se on 25532(a)? HEATING UNIT(OVER 100,(100 BTU)
Yea „a TOTAL:
Will the applicant wTo uilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) '$ (YgNCE DATE
which emit hazardou air taminanI as defined by the Bay Area Air
U'r,?�1TYManagementi? BOILER-COMP(3f8'OR 100,ON BTU) a��� L (� '1�i!'
III Yes '{r31 No 1A H 1 x
have read the baza s materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does nor currently have a tenant,that it is my NEW RESIDENTIAL MECIL SQ,l,F
responsibility to notify the occupant mf the requirements which must be mon O
sorI uance Certifcateof Occupancy.
Owner or authorpate
TOTAL: ISSUEDB
OFFICE COPY