21931 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prn'ea Identification 7 PERMIT NO.
Building Address: 21931
///;Z¢ Lu Pe'lo w e, "Dr. C"' w� rho Cu. esus ¢
wnere ama one: A A
f0haij
L I � �Ij Z$$—QjQ3 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: / Lie.No: APPLICATION I PERMIT 1 L
BUILDING-ELECTRICALPLUMBINGMKN'ICAL CATEGORY CONTROL.
Architect/Engineee Lic.Na
QTY ELECTRIC PERMIT FEE' BUILDING PERMIT INFO '
Address: PERMITISSUANCE �L/�-(J�
s-/, Ll 1:1 a
MECH
LICENSED CONTRACTOR'S DECLARATION
Ihth Sy o(trmthatlamlicm3ofthe ur nand off h.,r9(commrn AI'PLIANCESRESIDENHAL ]OB DESCRI'QON
•ngwlthinfon force andeffeon3o(the Businesand Profession Code,and my Z (( L \
license bins fora and effect. PANELS 6 ,l. Q
License Clan Cont UP TO 2DO ANTS
�`^ �1��
Date Contactor 201-1000 AMPS 11 11
ARCHITECPS DECLARATION
7 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT..
CO
2() Licensed Professional SIGNSELECIRICAL
6a OWNER-BUILDER DECLARATION
�n
Ihercby a(firmthat]am exempt(romihe Contractor'.License Law for the SPECIALCRCUIT/MISC
7p— f.Bowing reason.(5Mion 7031.5,Buslnes and Profesiom Code:My cityor
O G F TEMP.METDi OR POLE INS(.
K county which mquiresa permit toconstmct,alter,Improve,demolbh,orrepair
a`'E�C anystructure pdortoltslsmameabomquimstheappBant for such permit to - POWER DEVICES
Ufile a signed statement that M b licensed pursuant to the provisions of the
Contactor.License Law(Chapter 9(commencing with Section 7000)of Divi-
llIF�OS sion3oftheeuslnnsmd ProfmiomCode)orthatheIsexemptthemfromand SWIMMING POOL dECTRIC VALUATION
6
the basis for the alleged exemption. Any violation of Section 7031.5 by any O ��
appllant fora permit subjects the applicant to a civil penalty of no rronethan OUTLETS-SWITCHES-FIXTURES Om
a S m five hundred dolowner
of he pr. NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
Zf.. ❑I,as owner of the property,or he employees with wages m there sole
�7a
compensation,will d o the Business and of the siructam,is not intended s:TheCntractroro(f Law /
$�❑ ole(Sec.7074,Business and Professions Code:The Contractols License law
does not apply to an owner of property who builds or Improves theme,and II
�S^ who does such work himself or through his own employees,provided that such Ii v� / 1 SOC GOUT' ES.UNITS
impmvementsarenotintendedorooerect(orsalmthe wevegtheerwilln vetruildior ,TpL; . ., /1 __
P_
improvement Isaold withinoneyxarofcomplelbn,theowner-bu0derwill have
the enofpmvingthathedid net build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT ="� d PN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �/� 1
ntractors to construct the project(Sec.70Kq Bushes and Profas met Code:
The Contractor's License law does not apply to an.wner of property who pLTF3t-DRAIN&VENT-WA ) /
builds or improves thereon, and who contracts for such peppers with a FEE$ ARY '
co�nt ad.r(s)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
LJ 1 am exempt under Sa B h P C for this reason 'FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner a Date RECEB•T p
VORI (ANI 'OMPFNS ON DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y N_
' ❑I hereby affirm that I have a ce/ t to ae0-insure,m a
certificate of Workers Compensation Irenre
uram or a certified copytheof(Sec. RECEIPT Y
3800,Lab C.) CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
. RECEIPT a
Polity M GAS EA.SYSITM-OVER 4 01M
Com any BUILDING DIVISION FEES
�Certifidd copy Is hereby famished. CREASE/INDUSIRL WASTE INTERCEPTORPLANCHECKFEE
-
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WO R KERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Receipttl
(rhlssectiou need not be completed If the permit Is forom hundred dollars
(5100)grles.) WpTQt I[FATFR W/VFM/n Frf.R ENERGY FEE Y_ N
nce
1 cerifythat to the performaof the work for which this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
workers Compensationlaws of California. Date PAID
-
zZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date ReCei t#
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Workers Compensation provisions of the Labor TOTAL:
SW Code,you most forthwith comply with such provisions orthis permit shall be BUILDING FEE ,0
W > deemed revoked.
cONSTRU17HON LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
M O ane,of the work for which this permit Is Issued(Sec.3097,Civ.C.)
U _ Lendee.Name PLUMBING FEE
F Lemdesnddres QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OO isIred Ify ncet.Ihat I rectivire.dthbapplictlonandunte that the y.rdt...ces.lnformation
d vate law.
,
1 coingt building complywith andtyand countyibe repncesa.th,ceelaws PERMrr ISSUANCE FEESPAID:
-
} reytingtobuilding t constmemnandhamby dpropatyorlmPcctkentativosofthis
F Z city IWenter eon the above-mentioned propertyfor bape Cit Purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmies the City of Cupertino Date Receipttt
O against liabilities, costsand expenses which may in any wayaccrue AIR HANDLING Or=(TO 10,00)CFM) SUBTOTAL:
a ant City Inco ceo( agrantin othis. 't.
".; / 3 /s-9� AIR HAND NCUNT (OVER]O,000CM) CONSTRUCTION TAX
Sigrebtre of App a Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUSMATERIAS )ISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recef ttl
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health.nd Safety Code Section 25532(.)? HEATING UNIT(OVER 1W,"BTU) TOTAL:
❑ Yes M No
Will the applicant orfuture building occupant use equipment or devices VENDI-ATION FAN(SINGLE MID) ISSUANCE DATE
which coot hev rdous air contaminants as defined by the Bay Aic.Air
Quality Management District? BOILER-COMP PHPOR 100,01D BTU)Yea
M'®
4 Yes I—IFAA
N.
have read thehazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,0WEETU)
the California Health h Safety Code,Sections 25-%5,25533 and 25534. I MAR 151991
• understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.F7
responsibility,I.notify the occupant of the requircrents which must be met
prior to issuance of a Certificate of Occupancy.
IS �Q
Owner or authorlred agent Date TOTAL: ISSUED BY:
OFFICE COPY