21764 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ing Add seas: - 217 6 4
dM
n rs a . one: APPLICA IION SUBM I ITALA
T" �Zj1��C 'j2 3d� CITY OF CUPERTINO-BUILDING DIVISION
C Iraan;aName: C APPLICATION 1 PERMIT
M I CIO(-7— sue.Nmt BUILDINGELECTRICAL.PLUMBING-MECHAMCAL CATEGORY CONTROL#
,fib redZEi.o:— Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO-
BLI.Xi IJ-ELI PLUMB MiLlf
Address:. PERMITISSUANCE ❑ L1LICENSED CONTRACTOR'S DECLARATION
[hereby affirm that l am licensed under provisions of Chapter 9(mmmme. APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith Sedfon70110)Of Division3 ofthe BuslnessandProfessionaCode,and my n `
license Is in lea, ( and effect. 1, PANFIS/
Licenu Class�Lk.et. 6 (L+
Date 1— G�1__ContnRor S -u�(T�A.�(�j� UP TO0 AALU
a —sr ARCHITECPS DECLARATION
M, l understand my plans shall W used as public records OVER1000AMPS 5Q.FT.FLOOR AREA $/SQ.FT.
O LlmnaM Protevloml SIGNS ELECTRICAL
<w OWNER-BUILDER DECLARATION
In a FS SPECWLCIIiCUIT/1,415C
I" owing raffirmthat I amction7 17 Buroessa Contractor'sliced:Taw fort he
Z O 1.-' following reason.(section 7031.5,Business and Professions Code:Any tlty or -
Oyl...f� TEMP.METCA ORPOLE INSf.'
F� � countywhkh rcqulresa permit tocominct,alter,Improve,dennitsh,orrepair
anystructure prion,its lsaance,also requlrestheapplicanl forsuch permit to POWER DEVICES
Vfile a signed statement that he b)[ceded pursuant to the provisions of the
O Contractor's{ License law(Chapter 9(commencing with Section 7000)of Dist-
�n SWQ.SMING POOL ELECTRIC
F•�O� lee basis for
the elle e d Professions Any viothat lation f exempt<here(romand VALUATION
Yi the baso for the alleged exemption. Any violation of Section 70315 by any
g uvl<X OUTLETSSWITCHESFI%TURES V
QQ ape hundred aper dollars
the applicant tlWl penalty of not more than
c of five hundreddneof thepr.
I,as owner of the NEW RESIDENIIAl ELECTR SQFI'.
S70WE5 TYPE CONSTRUCTION
.. property,ormy, employeeswith
k�.< compensation,7lon,willdBu.ia th..d pro and cions ode:Th not intended or License d for
Law
5�D vie(Sec.7014,Business and professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
who dosssuch work himself orthrough hisown employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yea rof completion,the owner-build erwill have
th,£purden of proving that he did net build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FT.DDDZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �t
contractors to occulted the project(Sec.701y Business and Professions Code: I `
The Contractor's License law does not apply to so owner of property who ALTER-DRAIN&VENT-WATER 0'N
Wilds or Improves thereon, and who contrails for such pLojects with a FEE SUMMARY
m trama(s)licensed pursuant to the Contractor's License Law.
151 am exempt under Sec. B &P C for this mason BACK FLOW PROTECT.DEVICE'
OUTSIDE FE
Owner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT N
WOR KMAN COMPENSATION DECLARATION t FDOlJRES PER TRM '-t SCHOOLTAX Y_ N
❑I hereby affirm that I have a cortlficate of consent to self-Insure,ora 4 RECEB'I'N
ceN(late o(Worknrs Compersatimn Wuranm mracertifled ropy lherco!(Sec' C - 1 4 PARKFEE Y N
3800,lab C.). RECERrT N
Polky,#
Cum any G E BUILDING DIVISION FEES
ertMCcAlRedcopyk hereby tumied GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Certitied copybfikN with theci Int ction division.
CERHFICATEOK EMEROM WORKERS' GREASE PAID
COMPEN URANCE SEWER-SAMTARY-STO .<� Date ReceI t#
(I'Mssedlon need not be completed If the permit b(Drone hundred dollars
($1m)orlea�.) W;ATERHFATERW,/VFNT/ELEC ENERGYFEE Y N
I certify that in the performance of the work for whi h this pprtnii is blued,
I shall not c to any person In any manner n u to beco sub' to tM WAT IRSYSTEM/TREATING
Workers �timn lawso II to PAID
C• Z Applicant NE-WRESIDINTIALPLMB. SQ.FT. Date Recei t#
Z O NOTICE LICANT:B, ter making lhls'Cedif eo(Exemptlon,you
shwld become subject to the Workan'Comperuatlo ' vbioru of the Labor TOTAL:
code,you mustforthwith comply with each provisiorb arthts permit shoo be BUILDING •E CD
W _ deemM revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Ihereby affirmthat them Is,a construction lendingagency forthe perform �`� ELECTRIC FEE .-.
Z ance of thework forwhlch Nu permit Is Issued(Sec.3097,Civ.C.) TOTAL:
U O Iander's Name - PLUMBING FEE l 4.06
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Itertifythat1havereadthlsapp6atlonandmatethauheaboveinkrmation
O W bmmect.Iagreetoremplywithallcityand muntyordinananandstatelawe PERMITISSUANCE FEES PAID:
(L
} relating tobuilding construction,and herebyauthorize representativesofthb
F. N 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#
O agituathabilitles,Odgments,mks and expenses which may in any ayacerue AIR HANDLING UNIT 9010,M CFM) - SUBTOTAL:
a rot <on of the B 'I of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SI ure or p tirade/ omrador to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HALYRDOUS MATERIALS CLOSURE'Dam
future building occupy ore or handle hazardous HFATINGUMT(TO 100,000BTU) Date Recel t# _
rruterizl as defined by the Cupertino Municipal Code,Chapter 9.17,aniline
Ilealth and Safety CodS,5ection 25537(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes
- ' Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE '
which emit hazardous air conlamimnts as defined by the Bay Area Air d0
Quality Mawgemcnt Dist ict7 BOILER-COMP(3FR'OR 100.000 BTU)
[?Yee
have ad the ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER IW,"BTU) 7�--
�,
the California Ilealth&Safety Code,Sections 25S05,25533 and 25531. 1 -�r\1a8 r
understand that if the building does not currently have a tenant,that it b my NEW RESIDPN M,MEC#. SQ.Ff.
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Cortifiote of Occupancy. . { �� ,51
Owner r authorised agent - Date TOTAL: ISSUEDOY:
OFFICE COPY