21626APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Budding Add ,,:`g'
PERMIT NO.
• 21626
wnere rise: ane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A
Con annr,Name. Lic.No:
BUILDING FELECTRICAI MUMBINGMECHANICAL
CATEGORY COI�ItCl ll�
�p ,�J••
te ne r:
Archi/En Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrcu:
PERMITISSUANCE
'�]� ri
ISS IGS
LICENSED CONT
TRACTOR'S DECDECLA RION
Ihereby.fion, that l am llcensed under provisions of Chapter 9(commeno
Ingwith SC ton? )O(Ml sion3ofthe Budne dPmfeum.Code, and my
license is in hit force and effect.
APPLIANCFSRESIDENHAL
JOB DESCRR'RON
PANELS
Llcen,e Class Lle. #
Date Connector
�.V
201-1000AMI'S
ARCHITECT'S DECLARATION
lundemtandmyplamshallbeum mpubherecmds
Licensed Profemioral
OVER 1000AMP5
SQ. FT. FLOOR AREA
I I I 1 I IJ
$/SQ.HT.
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
I hereby afflrenthatIson exempt from the Contractor's License Law for the
3JI�B
SPECIALCIRC T/M
lPL(P.M INST.
following rea.on.(Sedlon 70313, Business and Pro(eolons Code: Anycity or
cauntywhichmquimsaper ttommtmMalter,Improve,demolish,orrepair
anystructure prlorto Its lesuance,eoorequlresthe appikantfor such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Charter 9(commencing with Section 7000) of Div I.
.lona of the BOsinem and Prolessiors Code) orthet he o exempt therefromand
POW)RD
gWIMMIN L
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the a pplicam to a civil penalty of not more than
five hundred dollars ($500),
or mstmploycture enathwa e a
f-11, as owner of the property, or my employees with wages [herr sole
OUILMSIVITC ES
NEW RESID LELECTR SQFT.
STORIESG
CON5IRLCTION'
n,will doth¢work a, r offeredfor
11
sale (Sec. 7044, Businessand Pmfesslore Code: The Contractors License lawdoes
Vmmpenaso
not apply to an owner of property who builds or Improves thence, and
doessuch work himself orthrough his own employees, provided that such
D9who I
improvements are not Intended orof(ered formic. If, howovet thebullding or
osld within oneyearo(completlon,the owner-builderwill haveben of proving that he did not build or improve for purpose ofsale.).
owner a( the property, am exclusively contracting with licensedPERMIT
ro radonto construct the project (Sec. 7044, Business and Profeaslors Code:The
TOTALImprovement
QTY. PLUMBING PERMITas
Tj
ISSUANCE
Canttactorb License Law does not apply to an owner of property who
builds or improves thereon, and who contracts (or such ptojeds with atoff,dor(. licensed pursuant to the Contractors License Law,
U I am a pt a cies ec. B & P C or t Is rcmon
ALTER -DRAIN & VENT- WATER am
RY
OUTSIDE' F
-
BACK FLOW PROT[CT. DEVICE
DRAINS FLOG ROOF, ARBA, COND, I2',jft
SANITARY Y_ N_
RECEIPT N
i00L TAX Y N
RECER T N
ri Own Date
%WORKMAN COMPENSATION DECLAR TON
❑I aemby affirm that I have a certificate of consent [o self- nsure, ora
Workenm
'Copersation Insurance oraartlfled copy thereof
certificate Lab C.)
PROD,00,Lab C.)
FECT URES' PER TRAP
S P.A._(Sec. GAA. SYSTEM -1 INCA OUTLETS
PARK FET Y
Policy#
TX
RECGAS-EA.
SYSTEM-OOVER
CD
Com any
BUILDING DIVISION FEES
DING
copy is hereby furnished.
❑ Cenmed ropy o filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECRFEE
PAID T f►�� �9
/awl
D f
GRE-ASETRAP
COMPENSATION INSURANCE
(Tho section need not be completed lithe permit o furan¢ hundred dollars
($1(0)orfess)
[he manweak so as to b co pemdt is Wued,
I carttfyll not that o any pehe rson In any
I shake not employ any person In say manner m u to become subject to the
Workers'Compensatlon laws o(GBfomo. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers Compemation provolone of the Labor
Code, you most forthwith comply with such prevoims ortho permit shall heB
deemed revoked.
Date Rec¢i IN
y-EWER-SANITARY-SI.DRM EA XpFI.
WATER HEATER W/VENT/RLECTR
Sb
ENERGY FEE Y N_
PAID
Dat¢ Recei fR
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.,_sQFI.
TOTAL:
N •E'3�9, b0
CONSTRUCTION LENDING AGENCY
SEISMIC FEE Gs Cp'
Iherebyaflirm that there Is a construction lending agency for the perform-
ance of the work for which this permit o c. 309
Issued (Se7, Cly. C.)
TOTAL:
'LECTRIC FEE
d ft
Lander¢ Name
Lander.Addevea
1oxmiythe Ihavereadthoapplimtlonanddatethattheabove Infom tion
Iscerrect. I agreeto complywith all cityand county ordinanmand data laws
PLUMBING FEE
QI'Y. MECHANICAL PERMIT FEE
MECHANICAL FEE
1 PERMIT ISSUANCE 151.
rEESPAID:
relating to building mmtmdlon, and hereby authorize mprescntatives of tho
7
city to enter upon the above-mentlened property, for Inspection purposes.
(We) agr to save, indemnify and keep harmless the City of Cupertino
ALTER OR ADD TO MECH.
Date R¢eeI tq
P
agalrm Bab llles,Judg le, sand expenses whichmay In anywayaccus
against sal C'ty in con a th gra ting of the. permit
O Q'_
AIR HANDLING UNIT (T010,000CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
nater
s pfiaan /Co ate t
HAZARD SMA RIALSDISCLOSURE
Will the appBant or future building occupant atom or handle hazardous,
material as defined by the Cupertino Municipal Code, Chapter 933 and the
PEATING UNIT (TO 100,000 BTU)
Dat¢ RCCeI Icy
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Health and SafetyCade Section 25532(a)?
❑ Yes I] No
VEMIMATION FAN (SINGLE REBID
ISSUA, NCILDATE
Will the applicant or future building occupant useequipment or devices
which emR hava dou. ab rontamoants as defined by the Bay Area Air
BOILER -COMP OFR' OR 100,000 BTU)
Quality Maaagemcot District?
qYes 12 us
havereadlealth a of
rect
Lp:Flys�a�'r-�'a
f,l
BORER-COMP(OVFR 100,000 BTU)
Code,
et Code, Se ons 255no5533 aChapte4.I
Ions 25505,25533
the Gltand tat th
o4 1
NEWRESIDENTIAL MECN. SQ.I7
If building otco
note tenancy that
a Land, that it
understand that Ifthethe
mymet
onpoyhavea
occupant beIs
r¢porsibllity to notify the occupant of the requlrnmenta which must be and
prior to bentanca of a Certificate of Occupancy.
#F
]�L 6 t, N4�411c�
Vr
ISSUED BY:
Owner or authonaed agent Data
-
TOTAL:
OFFICE COPY