21251 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bullete
Bulletin Pro d Identification
BulletinAddress:' PERMIT NO.
�ius-2 : 21251
nsrs ansa:
core CITY OF CUPERTINO-BUILDING DIVISION
Curtart '.NamP: Lie.No: APPLICATION /PERMIT �O'3-fid
Architect/Engineer. BUILDINC-ELECTRICAL MUMBING-MECHANICAL CATEGORY CONTROL p
Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
LI
om
PFRhTISSUANCE C FNSEDCONTR DEC ATON
Ihereby afiootlle.sedunderprovisions o(Chapte (on nc APPLIANCES-RESIDENTIAL
Ingwlth5d1on7000)..Divo(th.Busins..ndProlessoeCde,..dy ❑
JOBDESCN❑HON
icenu efient. PA
L :N 6ice. KQOUKr
❑
.it Contractor �s — UP TO 2DOAleS
G; Is•j-
CHITEGTSDECLARATION �,a.c. 201-1000AMP5
0Z0 Iundentondmypiatush.Hbeuaedaspubllcrem
rds� OVER U6IOW AMPS - SQ.Ff.FLOOR AREA g/SQ, ..
Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIALCRCUfT/M '
Ihembyaf1.that lamexempt fromtheContractorsLicense Law for the -
O .. following reason.(Section 7031.5,Business and Professions Code:Any city or
PIS county which requires a permit to construct,alter,improve,demolish,or repair TEMP.MEHR POLE INS(.
$$ v anystmu mprlortoitsissuance,alaorequlrestheappHuntforsuchpen tto ppyygR DEVICES
O file a signed statement that he is Bcansed pursuant to the provisions.f the
u,�i'i Contractors License Law(Chapter 9(rommeneing with Secion 7000)of� Divi- SWIMMING POOL EL C 0a aon3 ofthe Business and PrefealoneCode)orthat hale exempt therefromand '
the basis for the alleged exemption. Any violation of Section 70115 by any VALUATION
OUTLE'ISSWI - ES
p0 applicant for i petent,subjects the applicant to a civil pens By of net '..than
ee� live honored dollen($500).
�j I,as owner o!the ro my p yearsNEW RESIDENTIA L
q^�o ❑ p party,or em I° with wages as thSQFSTORIES T
T. YPE CONSTRUCTION
e sole
rompenaaHory wllldothe work endthes[rudureisnoHntended or o!lrtd(or �
sale(Sec.7044,Business and Pro(eeakns Code:The Contractols License Law
dace not apply to an owner o(property who buEids or improves thereon,and -
whodceasuchworkhimselforthrough Meownemployens, R
OGROU
providedthatsuch CC. Ir ES UNITS
Improvements are not Intended oro((ered loreale.I(,howevegthebulldinger TOTAL:
ImprovemerdusoMwithln.neyearofcompketiorythe courser-bu0derwill have '
tt�e�trden ofprovingthat he did na build orimprove(or purpose otaste.). QTY, PL B PER (T FEE
u I,as owner of the property,am exclusively contracting with licensed Pf.00D ZONE APN
contractors to ronstrudthe project(Sec.7044,BuaNessand Protesslons Code: PERMIT ISSU
]fie Contactors Llcenss Law dcea oat apply to en owner of property who
bullas t Improves thereon,and who rontncts(or such ptvjede with a ALTIILDRAIN& -WATER(EA)
cq[ltjactoKs)Bmnxd pursuant to the Contractor's License Law. FEE SUMMARY
L,J I am exempt under Sec B k P C for this reason BACK FLAW PR T.DEVICE
.Owner Date DRAINS ROOF,AREA,COND. SANITARY Y—
WORKMAN COMPENSATION DECLARATIONRECEIPT B
❑f hereby affirm that I have a certificate of consent to self-Insure,or a AURES'PER TRAP SCHOOL TAX y N
caritEram of Worken'Compeswtlon Insurance Ora cartifled ropythereof(Sec. RECEIPTM
3800,Lab C3 GAS EA.SYSTEM-I INC.4 OUTLET PARK FEE Y N
Policyp �
Com RECIIPI'.p
any - GAS FA.SYSTEAf-0VERd(EA) BUILDING DIVISIONFEES
❑
Certified copy is hereby te _Certified ropy V(fled withh the city city Inspedlon division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
i COMPENSATIONINSURANCE SEWER-SANITARYEA 20OFT Date Recei t#
(This eedlon need net be completed If the permit is(Drone hundred dollars
($100)orleth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
111 rut that employ
any d.I-any work.as A.become
issue,,
I shake not empty any peau.In any manner n ns to berom cubjed to the
Workers Compensation WATER SYSTEM/TREATING Lawe of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:H,eller making this Certlllote of Fxemptiory you NEW RESIDENTIAL PLMB,__SQ,PT. Date Recei f#
W
should become subject In the Workers'Compensation provisions of the Labor :TOTAL:
Curia,you=at forthwith comply with such provisions orthis perhall be '
W > deemed revokad. mit sBUILDING FEE
t1 CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
I hereby a(Rrm that there Is a constroitlon lending agency for the perform ELECTRIC FEE
0 O aam.f the workforwhlch this permit is issued(Sm.3W7,Civ.C.) TOTAL;
V _ Lender's Name PLUMBING FEE
Iy h Lep a rsaaaraaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W belt.Iagrlhavexfiply with
ailcit and
ordinances tion
is rowed.lagree to comply wlthallcityand county ordlnanres and elahlaws PERMIT ISSUANCE FEESPAID:
>- N reacting to building construction,and hereby authorize representatives of this
dtyto to upontheabove-onentbneaproperty for Inspection Purposes, ' ALTER OR ADD TO MECH. .,
V — (We)agree to indemnity an d keep harmless the City of Cupertino Date Reeei t#
against lisbWI ..is'coatsin x n khmaylnanyway.ecron AIRHANDONGUNH(TOIB,OWCFM) P
agar gala Cit nsequenceo e n ng this permit. SUBTOTAL'.'
(cam AIR HANDLING UNIT(OVER I0,0o0CFM) CONSTRUCTION TAX
Signature ofP C qr Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
f ZA O MA' ALS DISCLOSURE
Willthea ll or to ullding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Reaei t#
Health and Safety Ccdcckxa 25532(.)7 HEATING UNIT(OVER 100,OW BTU)
F-1Yea No
Wllitheapplicantor tore TOTAL;
building ..equipment or devices VFNDLATION FAN REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management D'u d2 BOILER-COMPOHIPOR100,0006TO _
EA,
Yes' No
aha stead the bazar ousmatedalsmquimm n[sunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU))
the California Health h Safety Code,Sections 25505,25533 and 25534. I Lill
understand that if the building does not correctly have a tenant,that it is H.my NEW RESIDENTIAL MEC - SQ.Fr SS''
responsibility to notify the occupant of the requirements which must be mat
prior to issue nm of a Certificate of Occupancy. OCT O wKM
Owner or authorized agent - Date
TOTAL: ISSUED BY:
OFFICE COPY