21607APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PELMITNO.
Building Address:
21607 1^O7
Phone:
A A A
,a . - �- ;-� _Y,sr
CITY OF CUPERTINO-BUILDING DIVISION
Ce aenr'Mm.: Lic.No
APPLICATION I PERMIT
fl C
BUILDINGELECTRICAL PLUMBING-MECHAMCAL
CATEGORY
CONTROL N ,
Arc ItM/Engineer. _ Lic. No:
QTY ELECTRIC PERMIT FEE'
BUILDING PERMIT INFO
Address:\
PFRMETISSUANCE '] Inv
ly 7 '
LICENSED CONTRACTOR'S DECLARATION
IMreb affirm that lam Bcros dander Islons of Cha r9 mmmm
Y P� . (
ingwith Section?(100)at Dioffa o(ihe Businessand fesslonsCode, and my
license is in full fo and d(ect. N
�ts� �
Data Class_-. j_Lie.N l:T
Date 1'7 -7 f Contractor pI,/.Trs/
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
APPLIANCFSRESIDEMIAL
JOB DESCRIPTION
('J-y�''�—{.�(') p C7
p lkj l u` P�'L•
-
PANELS _
201-1000A.MPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
'
SPECIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirenthat I am exempt from the Contractor's License Law for the
TEMP.METERORPOLEINST.
' following reason. (Section 7031.5, Business and Professions Code: Any city or
montywhich regWres a peanut to mmtrun, alter, Improve, dennlish,or repair
anystrocture plorm its sausexce,also requirestheappBmnt for such permit to
file a signed statement that he b licensed pursuant to the provisims of the
POWER DEVICES
'
SWIMMING POOL ELECTRIC
-
LTEETSSWIICHESFIKTURES
Contractor's License Law (Chapter9(menmencing with Section 7000) of Divi-
sion3 of the Business and Profeselons Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appBant tons permit subjectstheapplicant to a civil penalty of not morethan
[� VALUATION
five hundred dollars ($SM.
❑ I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ'Fr'
STORIES TYPE CONSTRUCTION
compensation,willelothe work andthestructurc V not intended or offered for
'
sale (Sec 7044, Business and Professions Cods: The Contractor's License Law
1
TOTAL: ,� I
does not apply loan owner of property who builds or improves thereon, and
who does such work himself or through his own employees, provided that such
Imm
proveents are not intended oroffered for sale. If, however, thebuilding or
Improvement issold within oneyearofcompletlon, the owner-budderwill have
OCC GROUP RES. UNITS
tlA�urdenof proving that he did notbuadorimproveforpurposeorsale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Ser. 7044, Business and Profession, Code:
QTy, PLUMBING PERMIT FEE
FLOOD ZONE APN
PERMIT ISSUANCE
The Contractors License Law does net apply to an owner of property who
Wilds or improves thereon, contracts such n, and who conttar ch Ptojecv With a
ce tfad r(s) licensed pursuant to the Cmurannrs License Law.
L -,J I am exempt under Sec. B A P C for this reason
ALTER -DRAIN & VFN'I- WATER (EA)
FEE SUMMARY.
BACK FLOW PROTECT. DEVICE
OUTSIDEFEES
DRAINS FLOOR, ROOF, AREA, GOND.
SANITARY ftECEIPI'N
Owner Data
WOR"AN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificateFTXTDRES
of consent to self -insure, or a
certificate ofWorkeri Comperwtlon Insurance or a unified copy thereof(See.
380D, Lab C.I
I'oliryp_ [��g k:'�5 ��••��
P6A LRfnn �Q
LT Y_ N_
j j RECEIPT N
GAS FA.SYSTEMd INC.40[7fL[TS:-
, ), f 0 —
A� ( N
E Y—
RECEIPTN
GAS FA. SySIFM 4'(EA)L'V
Com ray
BUILDING DIVISION FEES
0 Certified copy E filedwtumbad'
❑Certified copy Ufiled with the city inspection division.
CERTIFICATEOFEKEMPTION FROM WORKERS'
GREASE/IN $TRL4 Fl RCEPfo
✓a"atL 3 0
LANCHECK FEE
9
PAID—)
GREASE
COMPENSATION INSURANCE
(fhissection need oat be, completed If the permit V forone hundred dollars
Date Remi t#
SEWER-SANRARY-STORM FA. 200F7.
WATER IIFATFR W/VENT/ELECTR
ENERGY FEE Y N
(SIMM or less.)
I certify that in the pertormanesof the work forwhich this permit is issued,
WATER SYSIFM/TREATING
I shall not employ any person in any runner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
of emption, you
NOTICE TO APPLICANT. If, after making this Cerlaie Ex
fif
should berome subject to the Workcn'Compen,ation provisions of the Labor
Code, you most forthwith comply with such provisions orthls permit shall be
deemed revoked.
NEWRESIDENTIALPLMB. SQ.IT.
Date Recei I#
^
TOTAL:
BUILDING FEE
Oct
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform-
aof the work for which this permit'sbwed(Sec.3 ,Civ. C.)
!ceders Name
Imnlfythatlluvemadthsapplicatlonan datethattheaboveinformation
iscorrect. l agree to comply with all city and county ordinances and state laws
TOTAL: `t�s(x2
ELECTRIC FEE
QTY. MECHANICAL -PERMIT FEE
PLUMBING FEEleder'sAddmaN
MECHANICALFEE
-
PERMIT ISSUANCE �„�
FEES PAID:
relating to building mnstroction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, indemnify an it keep harmless the City of Cu pertlno
against llabllitks, ydgments, costsand expenses which may In anywayamue
ALTER OR ADD TO MECH.
Date Receipt#
MR}IANDLING UNIT (TO 10,000CFM,)
SUBTOTAL:
againsteal ityin cen of I grain ng efthis peanut.
i.
AIR HANDLING UNTL (OVER 10,000 CFM)
CONSTRUCTION TAX
Sigw ppBant/Contractor Date
EXIBAUSTIIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
,
HEATING UNIT (TO 100,000 BTL!)
Date Recei t#
Will the applicant or homes building occupant storeor handle havrdous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ilealth and Safety Code Section 25532(a)?
❑ Yes [2'No
}[EATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RFSID) Lel\
�L�
ISSUIV
Williheappliant or future building occupant uaeequlpmentordevicns
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District?
4Yes. ❑❑No
have read thehaz rdona materials requirements nnderGhapter6.95 of
I�
(a �.C$ U a�
-
BOILER -COMP (311POR 100,000 BTU)
BOILER-COMP(OVQt 100,0006N)
the Callomia }lealth L s,(ety Code, Sentara 25505, 23533 and 25534.1
understand tM1at if thebullding does not currently have atenant, that itumy
responsibility to not ify the occu pa at of the requirements wh ich must be met
'.
'
p�
Jv eat
NEW RFSIDENI7AL MECH. SQ.FI'.
prior to Issuce anof a Certificum of Occupancy.
Zsoap
ISSUED BY.—
Owner or authorized agent Data
- TOTAL: /
OFFICE COPY