21660 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bonding paL•s:000s 21660
where m
ae: one: - p
CITY OF CUPERTINO-BUILDING DIVISION
Cont, LIc.N. APPLICATION I PERMIT 1
BUILDINGfl,EcTmcAL-PLUMBINGMECHANICAL CATEGORY CO ObpF j
Architect/Engineer. Lie N. OSI
QTY - ELECTRIC PERMIT FEE
yy��- - BUILDING PERMIT INFO-.
Address: PERMITISSUANCE _Z'CV
�I
LICENSED CONTRACTOR'S DECLARATION L(9
I hereby affirm that l am licensed under provisions of Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DhSCRB'TION
ingwith Setion 7WO)of Divislon3oftheguslnesaandl'rolessions Code,and my
license is in full f and effect. PANELS �.
License Chss WLIe M
Date Contra
ARCHITE 201-1000 AMPS
qqqq in zu0�0 lu➢d�jeland my plain shall be usd u public record a. OVER TWO AMPS SQ.Fr.FLOORAREA �O.l-T�
LI rofeaslonzl SIGNSELECTRICAL VO t
Q w OWNER-BUILDER DECLARATION
1n E3 SPECIALCB2CUIT/MLSC
Iherei., owing yaf0nnthaton 7031 B.gm,the Contractor's License lawforthe
7.OM"Oy following reumn.(Section 7031.5,Business and Professions Code:Anydtyor
OZ' F.W TEMP.METER OR POLE INST.
� countywhich rcqulrcsa perMttocorstwct,alteq improve,demoilsh,orrepalr
aanystm=mpriortolts iswance,aborequlrestheappliantforwchpermitto POWER DEVICES
O a O file a signed statement that he Is licensed pursuant to the previsions of the
3 Contractor§License Law(Chapter 9(commencing with Section 7000)of Divl- SWBdMING R70L ELECTRIC VALUATION
F,El
sion3ofthe Busineuand Profmiow Code)orthathe9emmpttherefromand �^.p, �
the baso for the alleged exemption. Any violation of Stolon 70315 by any L(�' OUTLE7SSWITCHFSFIXTURFS ,aa
applicant fora permit subjectstheappiicanitoacivil penalty ifnat mmethan V"r' Oleo.
w �� five hundrd dollars($500). NEW RESIDENTIAL ELECTR �"'���
I,ascwnerofthe 'AFL STORIES TYPE CONSTRUCTION
e work,y,or my employees with wages r their sole
cote 01A will oetheworksessionstructureh not intended or offered for
5 p sale(Sc.(Sec 7044,Business and Professions Code:The Contranots License Taw
$ does not apply to an owner of property,who Wilds or improves themon,and OCC.GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not intended oroffered for sale.I(howevegthebuildingor TOTAL: t&00
improvement(ssold withinoneyearofcompletiogtheowner-W Oderwill have
mghu,denuf provmgthat he did nm Wtla or improve rurpurposeufsale.). QTy. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCEcontractors to construct the project(Sec.7014 Business and Professions Code: s
The Contractor's License Law does not apply to an owner a property who ALTER-DRAIN&VENTWATER(FA) s m
Wilds or improves - -
thereon, and who contracts for such pipjects with a FEE SUMMARY
�gIlt{aRor(s)hunsedpumuanttothe Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B& P C for this reason
DRAINS FLOOR ROOF,A �O' SANITARY Y N_
OUTSIDE FELS
Owner Date CON RECEIPT#
WORKMAN COMPENSATION DECLARATION FiXTURFS Pa TRAP SCHOOL TAX Y N_
❑I hereby a rke that I have a certifiate of consent to opythwre,or RECEIPT M
certiflabC.) rkeri compensation]uurance ora artl(hd ropythero((Sec. GAS EA.SYSTEM-1 INCA OUTLETS �r Cr/ PARK FE Y N
Polis Isis CJ RF EIPTN
Policy N CAS,EA.SYSIFAf-OVER Com ny - BUILDING DIV]SION FE ES
C Certified copy la hereby fumi.hed GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMFTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi t Q`-ILO
(This section need not be completed"Jthe permit isfor are hundreddollars
(SIM)or less) WATER HEATER w/VFM/ELECTR ENERGY FEE Y_ N
I certify that N the perlormanceof the work forwhlch this permit Is Owed,
1 shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING \q
Workers'Compensatlon Laws of Califomla.Date PAID1 `
O Z NOTIAppliCE
NEWRESIDENTIALPLMB. SQ.FI'. Date Remi t#�O�'1.�
ZO NOTICEcome subject
makingthislateof Exemption,you '
should you us eforth it the Workers'Compensationprovisions
orchis permit s Labor TOTAL:
>ccW Code,you must forthwith comply with wchprevisbmorthl.permit sM1allW dBLU N FEE
W deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
d o I hereby affrenthat there Is a construction lending agency for the perform- Co ELECTRIC FEE Q7
:) Z anre ofthe work for which this permit is iswd(Sec.3097,CL,C.) r TOTAL:
L) O Lender'.Name PLUMBING FEE
LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certilythat l have mad thbapplicitio...d GatethAtheabove Information
M iscorrect.l egree to complywith all city and county ordinances and state laws PERMIT ISSUANCE 1�..� FEES PAID:
>. W - relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for Inspection purpoxa._ f ALTMORADDTOMECH. . Date Receipt#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino OO
against liabilities,Iudgmets s]sind expenw.whieh may in..yw.y.ccree AIR HANDLING UNIT(TO 10,000 CFM) gaQ7 SUBTOTAL:
agahst a city m ohne gavtmg onto.Pennm' CONSTR ON TAX
e - S AIRHANDLINGUNIT(OVEt I0,000CFM)
SignatureApp nt/Contractor Date EXHAUSTHOOD(W/O=) G ION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 91
Will the applicant or future building occupant store or handle havardous HEATING UMT(TO 100,000 BTU) Dat Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Ilealthana SafetyCYes ed,I,Seaion25532(a)? HEATING UNIT(OVER 100,000 BTU) sa�� TOTAL:
❑Will the applicant r2
lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - pytn � SUANCE DATE
whkh emit hazardou.aircontarinanls as defined by the Bay Area Ara
QuNo
ality Management DiJ's�tIrict? BOILER-COMP(31IPOR 100,0(0 BTU1
4Y.
ha a mad the hazasTouui materials requirements under Chapter 6.95 of BOILER-COMP(Ova100,000 BTU)
the California Health&Safety Code,S fora 25505,2533 and 2534. 1 �LLFF!!OO^^IILLii11PR�\
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. �
responsibility to notify the ompant of the requirements which most be met
to u e of a Ce CI'fy / n�i,i
prior ficat Occupancy
� 1
Ow out ire 4age Date
TOTAL:
OFFICE COPY