21679 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProjectIdentification PERMIT NO.
so WA
21 679_
CITY OF CUPERTINO-BUILDING DIVISIONAPPLICATION / PERMITBUILDING-ELBCTRICAIPLUMBING-MECHAMCAL CATEGORY Uc.No: ELECTRICPERMFF FE^LE^ BUILDING PERMIT INFO
PERMITISSUANCE C 00 !] ❑ ❑
a LICENSEDCONTRACTOR'S DECLARATION
I hereby a(Umnthat l am licensed under provisions o(Chapter9(commeno- APPLIANCES-RESIDENTIAL ) JOB
LlDiceiaatne (ect. i
D_S�J/
Tl �o%wlthSedhw )° vlson3ofihe BusnnsandPrefessionsCde,and my PANELS
' �CTHEN 101-100APSARCHITE Contra /��X /7i
d
e% X
{Q+±WXI understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
00 E Licensed Professional SIGNS ELECTRICAL 9D
OWNER-BUILDER DECLARATION
fa a a SPFCIALCIRCUIT/MLSC
71.,Ya owinghereby a(on.(Seton7031exempt from the d ProfRor'n License Law for the
following remora.(Section7031S,t to Businessand Pimpmve Code:Any dry it
O �. iTMP.METER LE[NST.
�O rountywhuh requlrcsapermittoconstnd,alter,lmpreve,demollah,or repair ,
q11 anystrudure prior to Its bsuaree,alsorequeastheapplleam forsuch permit to POWERDEVICES
R C file a signed statement that he V licensed pursuant to the provisions of the
3°i Contndora License Law(Chapter9(commendngwith Sect .7000).fDivi- VALUATI(]QL^1
SOS the basis for
the elle e d ProfessionC Any
violhrthe f Smi ptthereS by any SWNShING C �
O the bash(or the alleged exemption. Any violation of Section 7011.5 by anyE.� .�
CM>u
applicant for a permit subjects the applicant to a civil penalty effect more than '10f
Bee hundred dollars($SM.
I,asowmrofthe ro RESID EL STORIES TYPE CONSTRUCTION
7�n e perry,d my employee with wages as their sole
C peZ 7Q Bow0he work.andthes Cdurebn ontrocdedo License
dw
X O sale(Sec 7044,to a�u�as and f property
rope ty Code:TTre or Improve,themon Law
5� whodo apply work owner offprough his wnemaorlmpmveadMreon,and OCC.GROUP RFS.UNITS
does whodoe9 such mentsa orkhiIntend d rough hleownemploye=;providedthatsuch 1
Improvements cold tintendedorooerect(orsak the-wever,thebullding or TAL: L a
improvement V sold wlthinoneyearofcompldioMthe°wnervbu0derwillhsve
tl),Jryrcinofpmving that he did net build or Improve for purpose o(ule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"I, s owner of the property,am exclusively contracting with limned PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner a property who ALTER-DRAIN kVENT-WATER(G)
W title or l�.provee thereon, and who contracts ins such w.ajeds with a FEE SUMMARY
co aa/%SY^_exemlicept under Sntrothe Contractors Llcenm Law. BACK FLOW PROTECT.DEVICE
exempt under Sec B k P C for this remora
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
ner Date RECEIPT If
WORK MAN COMPENSATION DECLARATION. FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby a(((rm that']have o Insurance
of consent to self-insure,tnerso ora RECEIPT X
380cartd,Iate o(Wor onlnurance oracertl(kd copy[here=f(Sec. GAS EA.SYSTEM-1 INCAOUTLE S PARKFEE Y N
Polis lab RECEIPT#
Policy EE
a 9 CAS EA.SYSEEMAVER 4(EA)
Cram anv � ( BUILDING DIVISION FEES
uJ1errdf c psy�i�Aby�umished. GREASE/INDUSTRL WASTE INTERCEPTORPLANCHECK PEE 2-4,60
_e,Zd copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Dale RCCeI t#
(Thissedion need not be completed If the permit is for one hundred dollars
($100)orless.) WATER HEATER w/VENT/E(-p.cTR ENERGY FEE Y - N
I mdifythat to the performance of thework f=rwhlch this permit is Issued, —
I shall note any,p=.If any manner m as to become subject to the WATER SYSTEM/TAG TING
Volkers' nestl=e Laws of California.Date AID
O Z Appll - NEW RESIDENTIAL PLMB. Date Remi tN
Z NO TO APPLICANT:
IL after nuking this Certiflrate of Exemption,you
should become subject to the Workers'Compeasation provision of the Labor TOTAL:
N Code,you most forthwith comply with such provision mthis perrrdbhall be
LMj deemed revoked. MOLDING FEE
LI IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE S^
Z (hereby affirm that them is a construction lending agency the perform- TOTAL: JrE
ELECTRIC FEE t a
ance°fthe work for h this permit la tested(Sec.3097,Civ.C.)
LL O Lender's Name_Q _ MECHAPLUMBINICAL
FEE
ly U Leader.Addlyth Wv_ QTY. MECHANICAL PERMITMECHANICAL FEE
O W comet.
Ia haveready with allcityndmuntyordina abovedmatelaw,
1 la<orrcd.]agreeto comply with andtyandcountyism representatives
mate PERMIT ISSUANCE FEES PAID:
} W relat ng,to o enteruilding pow the aboveron boned hereby property
orize pedlo nputivosen;.
H Z city to enter upon the above-mentioned property for lrupMlon purpose. ALTFR OR ADDTO MECH. Date Recei t#
— (Wc)a tom ,Indemolfy an d keep harrtdess the City of Cupertino P
againstlla t s,' menta,costsandexperse icheraylnanywayaceres AIR HANDLING UNIT(170 I0,000CFM) SUBTOTAL:
sgains ity a n i ant fthis e —
AIRHALADLINGUNIT(OVER10,000CIM) CONSTRUCTION TAX
r
igntu pplinn ntractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA DOUSMATER[ALS DI SC'WSURE
Wllltheappilcanto future building occupant store or handle hazardous HEATING UNIT CID 100,000 BTU) L�
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Date Reeei f
Ikallh and Sa(etyC Ion 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA6.
❑Yes 01I{-N10 '
Will the applicant or(utuie building occupant use equlprrcnt or devices VENTILATION FAN(SINGLE RMD) 1$$IJ
which emit hazardous air contaminants as defined by the Bay Area Air r,QeDATE
Quality Management Dtstrid7 BOILER-COMP OHP OR 100,000 BTU)
4Ycs G. 'I Q
haveroad the harm us materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,00007 U) ;:��� 3 U P�Y�
the California Health k Safety Code,Sections 25505,8533 and 75534.'] r
.,it stars hatifhe building does not correctly have a tenant,that it 6 my NEW RESIDENTIAL MECH. SQ.FT
respon t i the occupant of the Femarrats which most be rest
Prior 1 a
Ovvocrolidifliorrive gent Data �sr�
TOTAL: ISSUEDBY: JL�1F_
OFFICE COPY