21889 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: a� (�n n
son21889
eone: p A p
IT
CITY OF CUPERTINO-BUILDING DIVISION
^�rt 'q Name: APPLICATION I PERMIT 3 S�
/ ` -x BUfLDING-ELECMCALPLUMBING-MECH LAICAL CATEGORY CONTROL p
rcMtect/Engl eer.
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: -
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S
pr DECLARATION
Ihthb to0mnehatlaiv Rcrosedhe Bug errand mChapter9(commmc APPLIANCES-RESIDENTIAL JOB DFSCRErTION
Ingwith5edlon7(100)of Divlslon3 ofthe Buslnessand Pm(eaalonaCode,and my ��2
license is In full((pp�E d onus or PANELS r
d.
Limnse ClaZj' , Lk.p 1
Date-zr_Q_t_ContnRor
( �ARCHITECT•SDE IA ATION 201.1000 AMPS
rc0 Z I understand my plans shall he used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FI.
CO
2
(0 Limned Professional SIGNS ELECTRICAL
6c. OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
owing ream.
that I CSctien xempt(roess. dm the Profctsion.0 ne:Law fort he
followingreason.iresa e70115,Buelness and Profealona Cade:Any city or
I"'t,9- auunrywhich rcqubesa pemdt toconstroct,alter,improve,demelbh,orrepair TFMP.METERORPOLEINSf.
gg� .a anystructurc prforto its issuance also requirothe applicant for such permit to
1-" V file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3u, Contractor'.License Law(Chapter9(comumncingwith Section7000)of. Divi- SWIMMING POOL ELECTRIC
sion3ofthe Bualneaand Pmf.ss .CWe)arthathebe.a ptthemfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7MLS by any
« applicant fora permit subjects the applicant to a civil penalty niece more than OUTLEISSWIICHESFIXfURIS -
e.py O five hundred dollars($SM.
0 ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFT. ES TYPE CONSTRUCTION
N�< compensation,willelothe work andthe structure'.not intended or offered for Nor/
O sale(Sec.7046,Business and Professions Code:The Contractor's License Law
�$.9 does not apply to an owner of property who builds or improves t hereon,and OCC.GROUP RFS.UNEfS
who does such work himself or through his own employees,provided that such
improvements are^cat Intended or offered for sale.If,however,the building or TOTAL:
Improvement issold within oneyearofcompletlon,the owner-builder will have
t rdcn of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE IgAO mZ - ATN
{as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contactors to construct the project(Sec.7014,Business and Protealom Code: Mco
The Contactor'.L1mnw Law dm nes apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pWiecta with a
<gDt(actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reason
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Date RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to se -Inane,rn a FIXTURES PER TRA l 8xt� SC iOOL TAX Y N_ r'
certl0mate o(Worken'Compensatton Insuranm aramrtifled apy(hereof(Sec. RECEIPT#
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy# RECEIPT#
Cam any GAS EA.SYSTEM-OVFR 4(EA) BUILDING DIVISIONFEEB
Certified copy is M1ed with t ecity GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city inspection division.
atted
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
la frn one hundred dollars SEWER-SANITARY-STORM EA 200FT Date Recei t#
Rhlsaction need nu be crnnpinted lithe perMl
($100)orina.) WATER HEATER W/VENT/ELECTR ENERCYFEE Y N
Performancerti(ythat in the Performance of the work fee whkhthis permit is Lsaed, N—
I shall nes employ any person in any manner a m
as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation laws of CaliforaW.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,afor making l his Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,Fr. Date Recel t#
should become subject to the Workers'Compessation provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions mthis permit shall he
W > dee^,ed rev^kad. BUIL12ING FE
d f] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyalflrm that there is a contraction lending agency for the perform,
7 Z anceof the workfor which this permit is issued(Sec 3097,Civ.C.) TOTAL. ELECTRIC FEE
V O Leader'.Nan¢
QTY. MECHANICAL PERMIT PEE PLUMBING FEE O\W
LL h I.enae:apaarea MECHANICAL FEE
O W Icertifythat l have read thsapplkattonand nate thattheabove information
1 Iscerenct.I agree to comply with all city and countyordinancesand gate taws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorise representatives of this
Z city to enter upon the abovo-nientioned property for Inspection purposes. ALMORADDTOMECH.
(We)agree to ave,Ind courtly an d keep harmless the City of Cu pertlno Date Receipt#
4agalngl�bdfflea,judgments,costa and expenses which may In any way accrue ATR HANDLING UNIT(TO I QOOO CFM) SUBTOTAL:in conseque oflhe grant Ing of this permit.- AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCJ'IONTAX
B Contract^ pate EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
H DO ERIALS DISCLOSURE
ese r future building occupant store or handle havardous HEATING UNIT(TO 10))000 BTT)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date ReceI t#
Ilea lth and Safety Code Section 25532(x)7HEATING UMT(OVER I W,000 BTU) 0
r] Y. �J Na TOTAL:
Will theSppllcant or fRture building part use equipment ordevims VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OtIP OR 100,0())BTU) L''rl.sE✓
71 Yes n No
havereadthAh r�oua materials requirements under Chapter&95 of IKIILER-COMP(OVER 100,000 BTI) 10
the California fiealth&Safety Code,Sections 75505,25533 and 25534.1 I Irl T\ a lY �
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ,FT, Y
responsibility to sunce faeheicte of of the uparcyulrcmenh which must be nal
dor to issuance of really the- to of Occupancy.
Owner or authorized agent Date ISSUED BY: L
TOTAL:
OFFICE COPY