21046 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
buildlnx Pro'ed Identification PERMIT NO.
Building Addrea.: nab
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Tyz—Mrs pile,
5 /L I CITY OF CUPERTINO-BUILDING DIVISION N.1 QAT N►{icy' 1
Contractors Name: L . e' APPLICATION / PERMIT
- BUILDINGELECTRICALPLUMBINC MFLHAMCAL CATEGORY CONTROL N
Arditetl/En neer. Lie.Nm
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add... PERMITISSUANCE
LICENSED CONTRACTOR'$DECLARATION doKI 91 E9 X1
I hereby a(((rm that l am Licensed under provisions of Chapter 9(onsi APPLIANCESRESIDEM'IAL JOB DFSCRIPTION
tngwlth Senion7000)of DiA.1.3ofthe Bminnsandprofe..[..Code,and my
Ilcenss le in: rce end dfM. gl 1 PANELS C�� 1'�e'I'1..L N�CLJCZ�
Data
ism_ LIcN i'I � \1 �`
Date_ Contractor_
ARCHITECTSDEC ublicm ON 2(11-1000 AMP"'
�ZO lunderstand my plaes stall be used as publicrecords OVERIWO AMPS SQ. RARFA $/SQ.FT.
Ed�j Licensed Professional SIGNSELECTRICALCO T E R
tr'< OWNER-BUILDER DECLARATION SPECIALCBRCUTT/MLSC '
t- a (hereby affirm that l am exempt fromtheContractor's Llcenseliwforthe
2p following reason.(Section 7131.5,Business and Professions Code:Any city or
TEMP.METE20R POLE(NST. DATE
K5
countywhich rcqulmapermit romrutruct,alter,lmprove,demolhh,or repair
.a any structure prba
rto its issunce,alsorequires theappaont forsuch permit to POWER DEVICES
file a signed a.temest that he is licensed pursuant to the provisions of the
�Owl Contractors License Law(Chapter 9(commencing with Section 7000)ofDlvl-
O�p elon3 of theBuelnees and Pro(emloesCode)orthat hebexempttherefromand SWIMMING IDOL ELECTRIC VALUATION n/!1
Sn the basis for the alleged exemption. Any violation of Section 7WIS by any 2r1 cn �� a�^Q0
<� appllcent fora perreibubiresstheapplicant toativil penalty Mnot morethan OUTLETSSWITCF{FSEXTURFS Y♦/J W
five, a.ed owner dollars($500). NEW RLSIDENTIALELECTR_SQ.Fr. Slumus / TYPE CONSTRUCTION
7 G ❑T,as owner will
the property,or my employees with wage as offered
dole
com(Sec.7044,Business aworkandthes Code:re is he nt Contended oroffendfor
O sale(Sec. pplyto n owner
df premiow Code:The Contractors Licensehemon law
$� dh.d apph akhtnlmtbmhhlseperty obuilds nempoyce3,pveidedthn,and OCC.GRO(1P RES UNfTS
whoeseuNworkhimself edorough hieownemployees,providedthdiouch
Improvementsared withiintendneyear fcmplered ssle thehowever,nebuilderwdt g orhave TOTAL: s
Improvement b sold within oneyearo(complalory the ownervbullderwlll have
tflLj?urden of proving that he did nm build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contraders to construct the project(Sec 701/,Business and Professions Code:
The Contrsnarb Llcenm Law don not apply to an owner of property who �VR�A
builds or improves thereon, and who contracts fee such pipods with a ALTER-DRAIN&VENT-WATER LEA) W
owir.dor(s)Rcenssd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this reactors
•
OUTSIDEFEES
Owner DRAINS A,FLOOR,ROOF,ARECOND. SANITARY Y N Date
WORKMAN COMP L1gSAT1ON DECLARATION RECEIPT p
FJN UIRF-S.PER TRAP Za SCHOOLTAX Y N
❑I hereby affirm that I have o Insurance
a c of consent to sslf-imurc,ora RECEIVE N
M00'L.bC.)certificate of orkers'Compensatlen Wurancearacertlfled ropythereof 6ec. CAS FA.SYSfEM-1 WC.I OUTLETS PARKFEE Y N
PROD,lab C.)
1'alry N RECDING DI N
Cnm an GAS G.SYSIEM-0VERILEA)Y BUILDING DIVISION FEES
Certified copy is herebytehed. CREASE./INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
i(led copy b filed withh the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SALARY-STORM ��. Date Recei tN
U).,I..on need not ed completed tithe permit h!crone hundred dollars
(E700)orlthat
th WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertay thatIn oy he any Performance ewmkanfor
ast cern eermitls heed, — —
I shall not employ any person In any manner n m to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date ppJD
0 Z Appllant
Z O NOTICE TO APPLICANT:IQaRer making this Certificate of Bar ptlan,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei Iff
Hshould become subject to the Workers'Comperoatlon provisions of the Labor TOTAL:
fn Code,you at forthwith comply with such provisions or this permit shall be _ U D
9 deemed revoked. L
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
Z Ihembya(Brmthat there h a construction lendingagenry forthe perform TOTAL: ELECTRIC FEE ♦(5p
O ance of the work for which this pertNt is hsued(Sm 3097,Civ.C.)
V Tenders Name PLUMBING FEE
IL 1= Lendcra Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W IomtfythatI have read thisappllatbn and state thatthedbove infomatlon ^ a�
bonen.I agree to complywith all city and county ordinances and gate laws PERMELLWANCE I L( FEES PAID:
} O' relating tobullding matmction,and herebyauthorberepremntativedofthio
U) city to enter upon the above�mentioned property for inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against llebWtln,Jadgrrenb,cogeand expenssa which may inanywayacarue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL'
ago lest said City In consequence of the granting of this permit.
- AIR HANouNc UNIT(OVER 1D,noocr•M) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanbtore or handle hasardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertlo,Municipal Code,Chapter9.12,and the Date ReCel tN
I lealth and Safety Code tlion 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: tqT10
Yes No
Illthe
applicant o future building ocevpast use equipment or devices VENTILATION FAN(SINGLE RESID) 2 ISSIL&NCE DATE
which emit harard...air ondamlwn/a as defined by the Bay Area Air
• Quality Management D2�rict7 BOILER-COMP OHPOR 100,000 BTU)
4 Yn �GLNp SEP
I 1990
haveread sopa is Sfd Cried Sectio requirements 5533 and 25534,
1 of f70ILH&COMP(OVFR 100,000 BTU)
the Cd)IfarnlaHnlih&Safety Cade,Sectioti 75505,25573 and 75534, 1
understand that if the bu tiding does not m mntly have a tenant,that It b my NEW RESI DENTIAL MECH. cS FT.
rnporaibilitym.al eoccvpant of the requirements which must be red frl p�.
pdormbsuapkeo Cent of aupanry. CLtw (' d e IBA
Owner or authorund ager Date 4�-tT�4'�/,'�
TOTA4 ♦ ISSUED
OFFICE COPY