21886 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification .PERMIT NO.
Building Address: 21886
7nn
nen ante: APPUCAW93C97T7rAE=
CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: L o. s APPLICATION / PERMIT
L� BUILDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROLM
Architect/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO ;
Address: PERMITISSUANCE ')— .
LICENSED CONTRACTOR'S DECLARATION
]hereby affirm that lam licensed under provisions of Chapter9(mmmec APPLIANCES-RESIDENTIAL IOD DESCKJDIIION
ingwRh Section7000)of Divbion3 ofthe BusinessandPro(essionecode,and my
license is in hiD force and effect. PANELSLicense Claw Lk.Y
Date Contractor UP TO 2DOANU _
ARCHITECT'S DECLARATION 201-IODOAMIS
pZ I understand my plans shall be used as public records. OVER10DOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
µpgqqp! O
EJ�j Licensed Professional SICNSELFGTRICAL r n
Z
OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MLSC - // :� T=•
1, lowing reason.(Section
B tromthed Professions
icenseCode:law fort he
7Q followingreason.(Section7m15,Business and Professions Code:Asydtyor
�Gt,
TEMP.
c.O e TQrP.METER OR
POLE]NST.
cmntywchtesatomns'mct, pmvghr
aanystructure prior to its bustnalso esthe
applicant
forsucpermit I pQypR DEVICES
file a sisned statement that he it licensed pursuant to the provisions of th
I
Contractors License ILaw(Chapter9(commencing with Section 7000)of Divi- DA Ja SWIMMING POOL ELECTRIC
sron3o(the BusNessand ProfeASloru Code)orehat hebexempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLET&SMTCHFSRXTURES xC.b
�5Q applicant for a permit subjects the applicant to a civil penalty of nor room than
fivehundred
owner of
NEW RFMI)ENIIAL ELECTR SQFf. STORIES TYPE CONSTRUCTION
Epyyf as owner o(the property,or my employee with wages as their sale
76 c6mpematme,wBldo the work andthe structure is not intended or offered for
�O sale(Sec.7044,Business and Professions Cade:The Contractor's Limose Law
�e$2 does not apply to an owner ofproperty who builds or improve themes,and OCC.GROUIP RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not intended confireed for sale.ILhowever,thebuildingor TOTAL: -
improvement bsold within oneyearofcompletion,the owner-bu0derwlli have
Q15rdenof proving that he did notbulld orimprova for purpose ofsale.). QTY. PLUMBING PERMITFEE
FLOOD ZONE APN
PS L as owner of the property,am exclusively contracting with]lensed PERMITISSUANCEcon1
The Contract is Li vat Lawproject(Sec.7044,applyto Business and Professore Code: \ `
The Contractor's License Gov does not apply sct an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.to improve thereon, and who matter's roe such p.ojects with a 2et� FEE SUMMARY
tractmexemtunderds)licensed antSec.to the Contractor'sLicense Law. BACX FLOW PROTECT.DEVICE
•❑I am exempt under Sec B&P C for this mason
rS
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N OUTSIDE ,.
Owner Date - RIxEIP'C M
WORILMAN COMPENSATION DECLARATION !1 FIXTURES- SCI]OOL TAX Y_ N_
❑I hereby affirm that 1 have a certificate of consent to self-Insure,ora L S� RECEIPT 0
mrtiRraolWorkers Comperssauan]muranmmacertifkd mpytherco((Se<. GAEA.SYSTEM-1 PARKFEE M-1 INCAOUTLETS Y - N
3g3800,[abb CJ S RECEIPT M
PoliryR GAS FA.SYSTEM-OVER4(EA)
Com any BUILDING DIVISION FEES
ECertified copy Is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATEOFEXEMPfIONFROMWORKERV GREASEIAAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20017. Date Revel t#
(This section need not be completed If the permit b for one hundred dollars
($1M)oelow) WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
l mrtify that In the performormof the work forwhich this pemd'is Nsued,
I shall not employ any Person 1 zany Ener co es to b yp ct to the WATERSYSTEM/TREATING _ PAID .
Workers'Com et,^ yp ) f ! Date 77
/u-Z Applicant 66p3�� NEW RESIDENTIAL PLMB. SQFf. Date Re•tei t#
rZ O NOTICE TO APPLICefNT�7,afte/making this Certificate of Exemption,you
should become subject to the Workere'Compematlon provisions of the Labor TOTAL:
_ Code,you most forthwith comply with such provisions or this permit shall be BUILDING FE 00
deemed revoked. .
W �
CL CONSTRUCTION LENmmG ncencY SEISMIC FEE I Sb
Ihercbyaorkfowhic tisamretrustlonknSee.307,Cly. the perform- TOTAL: �� ELECTRIC FEE l.tc06
7 Z Lereof thework(or which thin permit bLcwed(Sec.3097,Civ.C.)
U O IzMcr'a Name PLUMBING FEE x
Leaders Address QTY. MECHANICAL PERMIT FEE
Qw Imrtlfythail have mad thoupphration and statethatme above Information MECHANICAL FEE
0. Iscomet.Idgme to mmp)ywith all dtyand county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
In retail ng to bu llding comlrurtion,a nd hereby authorize representatives of this
,city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date' Receipt#
V against liabilities,pdgments,cops and expense which may in any way accrue AIR HANDLING UNIT CFO 10,OW CFM) SUBTOTAL:
aga imt said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,(1W CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE `
Will the applicant or future building occupant store or hand le havrdous HEATING UMT(TO 100,000 BTU) Date Recei t#
materul as defined by the Cupertino Me nidpal Code,Chapter 9.1Z and the
Hea lth and Safety CodZ.Spctioo 26632(a)? HEATING UNIT(OVER 100,000 SM TOTAL:
71 Yea 2g No
Will the applicant or future building occupant use equipment or d evices VENTILATION FAN(SINGLE RESID) I4kfA§DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lity Management District?• BOILER-COMP OFBP OR 1110,009 BTU) _ yt�y
4Yes (i�No IrIP'1Il 4
havereadthehaa ouswtedab requirementsunderChapter6.95of BOILER-COMP(OVER 1D3,000 BTU)
the California'health&Safety Code,Sections 25505,25513 and 25534. 1
understand that lithe building dues not currently have a tenant,that It is my NEW RESIDEMIAL MECH. SQ.FT.
respowibility to notify the occupant of the requirements which most be met
prior to issuance of a CediT¢ate of Oa panty. -- "
314161 CYt?�i } c�
�.aut zed agent Date :
TOTAL: ISSUED OY
OFFICE COPY