21384 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PF7LWTh'O."
Balding Adareaa: - � � 21384
159 a 21 AV 4
rte's armpE one: APFERD=UBMII IALA
mCITY OF CUPERTINO-BUILDING DIVISION
Contractor's Nan 1 1 lrR
wk1� �Y' APPLICATION /PERMIT
L .No:
BUILDINGELECTRICAL PLUMBINGMECHAI ICAL CATEGORY CONTROL N
. Arch tea/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO ,
Address
PERMIT ISSUANCE }BLOG
�'. ❑ ❑ ❑
LICENSED that ED CONTRACTOR'S DECLARATION
the by ScctIo Irmlhatlamgolicensed heunder Busi essae,vof Chapterode,anenc APPOANCESRESIDEN[UL JOB DESCRIPTION
It. ISection 7UfA)of Di effect ofthe BuslnesaandProfesslonss;gde,and my
Brenn Is in fun fodnAarerred. / PANELS
Lice
D enonlract.r UP TO 20OAhUS
ARCHITECTS DECLARATION 201-1000AMPS
M2 I understand my plans shall be used as public rerords. OVER 1000 AMIS T. EA $/SQ.Ff.'
COC
U Licensed Profemiumi SIGNS ELECTRICAL
ImOWNER-BUILDER DECLARATION
SPEILCICIT,MSP,T�E/
R
0<Vn
..a following recon.(Seaton 7031 S,Business and Professions Code:Any ctty or
O Z s,u9 TEMP.METER OR POLE INST.
rES county clam requlrcsa Issuance,contactiresth,a prove,demobsh,or mit to
any stacNre statempriortoent
he Is atso sed pursuant to the rovEd m of
a POWER DEVICES
O 0 01e a signed statement that he ts licensed pursuant to the provblov o! the
7p,5 u,y
Contractor's License isw(Chapter 9(commenangwith Section 7000)ofDWI-
f;�05 skm3ofthe Buslneminl ProfmionCode)orthanhe6exemptthemfmmand SWP4MING IDOL ELECTRIC VALUATION
4 M the basis for the alleged exemption. Any violation of Section 70315 by any OITILE.BSWf.rcHFSHXIl1RE5 O
a appVant for a pencil subjects the applicant to a civil penalty of not more than It d
F^ five hundred dollars(4500).
❑I as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION'
, p petty,or my employees with wages r there sole
compensation,will Botheweak and the,Codvrehec intendedo ioffend!or
z, ❑
sale(Sec.70Kpply to an�owandfpropsiov Code:The orimpoves themeLow
i $ whodnet
essuchtoamm�eal olpmpertywhonemporimproovided ron,and
c-•�^ whodoesauch workhimself orthrough Msownemplayen,provided that such OCC.CROUP RIS.UNITS
Improvements are not Intended oroffered fovale.If,however,thebuilding or TOTAL:
tr pmvementbwMwithinonerarofcomplellon,theowner-builderwillluve
thrc*den of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to rovtrua the project(Sec.7014,Business and Professions Code:The Contractor's License Law does not apply to an owner a property who ALTER-DRAIN&VENTWATER(EN
Wilds or Improves thereon, and who contracts for s - -
uch ptojects with a FEE SUMMARY
coactor(s)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
u I am exempt under Sec. B&P C for this reasonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEBT N
WORKMAN COMPENSATION DECLARATION FIXgOgEq PERgRAP SCHOOL TAX Y_ N_
❑I hereby oricm that I have o Insurance
a c of consent to copy thereof
ora RECEIPT N
3800.a(e ofWorkeri Compevatlon]nsurance oracertifkd copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEF Y N
3800.lab C.) —
RECEIPT p
policy N GAS PA.Sl'STEA1-0VER 4(FA)
Cnm any BUILDING DIVISION FEES
❑pCeniOed ropy b hereby famished. GREASE/INDUSITtL WASTEINTFXCEPTOR PLANCHECK FEE
F1 Certified copy b filed with the city inspection division.
CERTIFICATE OF EfEM PTIONFROMWORKERF GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANTEARYSTORM EA 200FT Date Recei t#
(Thtssection need nut be completed If the permit ts foroa hundred dollars
($10(forless.) WATER HEATER w/vFNT/F�..FGTR ENERGYFEE Y N
I minma
minify that in the performance of the work lorwNch this permit is Issued,
I shall note ploy any person in any manner so me ject mite,
WATER SY$T[M/TREATING
worker:Co ns ti V CaEf mV. D t PAID
-
0 qqnn pp �
0 Z Applicant red I ted QARAO NEW RF9DFNTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO XPPLICANT:If,a er making this rtiflace of Exemption,you
should become subject to the Workai Compensation provision of the Labor TOTAL:
~ In Code,you must frmlw,uh comply with such vtslons or this rat shall be
LU — Py Pre, Pe BUILDING FEE x00
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC PEE I
IlZ eof the
orkfrwhicffirm that them tsa<onsiactlon ld(Sec. ag7,cy Cle. .) perform TOTAL: ELECTRIC FEE
L) O anceuf the work for which this pestis issued(Sec.3097,Civ.C.)
Ianeurn Name - PLUMBING FEE
LLF I.ender'sAddrom QTY. MECHANICALPERMIT FEE MECHANICALFEE
U Icertifythatl have read this appliadon and state that the above information
0 W tscorrect.tagreetocomply with allatyand countyordlnances and state lawn PERMIT ISSUANCE FEES PAID:
} V) A 'relaungtobWldingronswalon,and hercbyauthorixerepresentativesofthls
N � ,city to enter upon the above-mentiorN property for inspection purposes. ALTERORADDIDMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V N agamoliabilites,jodgmencs,cosband expenseswhich mayln anywayacave AIRHANDLINGIIIYITO0I0,0(XCFM) SUBTOTAL:
it, against said City In consauenre of the granting of this permit.
AIRHANDLiNGUhEff(0VERIQ0d3CFx1) CONSTRUCTION TAX
Signature of Appilam/Contactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stonier handle harardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the -
FNalthandSafetyCod ion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: s�
❑ Yes o
Will the applicant. fuNre building o<apant use equipment ordeviccs VENTILATION (SINGLE RESID) ISSUANCE DATE
` which eat harardous air contaminants as defined bythe Bay Area Air
Quality Management Ist a7 BOMER-COMP QHPOR 100,1109 BTU) PAIL)
`
Yes No
4havereadtheh. o a terials requirements underChapter 6.95 of BOILER-COMP(OVE IM,000BTU) I6/
the Glifmla Health&Safety Code,Sections 25506,25533 and 25534. I -
responsibilliity to if
the occupant of requirements which must be mel NEW RESIDENTIAL MECH. SQ.Ff.
underst that the B y NOV Ul 199t7 .
j prior iss.. cc old 1licac of Occv an . p�Ln
/m
ner or aul oriwd agent ate lJ TOTAL: ISSUED IIY:
OFFICE COPY