21991 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ett Identification - PERMIT NO,
Building Address: 21991
wM7 ams: hone: AFFUCAHONSUBMUIALDAIE
L&Jrq CITY OF CUPERTINO-BUILDING DIVISION �—rlax0. ��
ContractnrsName: Lic.No: APPLICATION I PERMIT
L0. BUILDING-ELECTRICAL PLUMEC
BING-MFIANICAL CATEGORY CONTROL It
Architect/Engineer. Lic.No: W -
' „BUILDING PERMIT INFO` `
(j QTY ELECTRIC-PERMIT' , FEE -
Address: ( PERMITISSUANCE l� �� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereb affremthot l am licensed under provisions of Cha r9 comment- APPUANCESRESIDENTIAL - -
Y P Pte ( JOB DESCRIPTION
Ingwiti ifon7000)ol d efeon3ofthe BusinessandPro(esstonsCode,and my -
Iicense is In foul re and effect. p 7 p d PANELS
b /
Licenu Cuss Lk.p •
Date Conmu,mr w.t. e-
ARCHITECTS DECLARATION 201-1000 AMPS
qqqZ I understand my plans shag be used as public records. OVER 1000 AMPS - SQ.FF.FLOOR AREA .$/SQ.FT.
Z Licensed Professional - SIGNS ELIC _ 1 A q = n3 "(1
�7/IrC/
Q OWNER-BUILDER DECLARATION - SPECIAL CIRC T/M u / •'I L
F, IhereblR
yarenthat I am exempt from the Contractor's Licence Law for the ^ ..
0 F: following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER S .
G countywhichrequlresapermittGmmtmdaltegimpmvedemollsh,orrepalr
Fl a any structure priorm its issuance,also requlresthe applicant forsuchpermlt to EWER �5 ��•//
file-a signed statement that he 1s licensed pursuant to the provisions of the ,
3 a Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- SWI 4D -L ELECTRIC - A •TION
O sion3ofthe Businessand Professions Code)orthathe Isemm therefromand
S the basis for the alleged exemption. Any violation of Section 7031.5 by any ..TL D I /
L tfora permit subjects the licantto a civil penalty ( of more than /'� OUTLETSSWITCHES-IT(URE9 `1I
ave hundred
P K PP P tyo n
e.?OO fivehundredsollanhepr. - ��.
� 9,L NEW RESIDENTIAL ELECTR STORIES ECONSIRUCTION
j.. ❑I,as owner l the property,or my employees with wages r there sole
compensation,wusBothe work and the structure isnot intended or offered for
N$a�O sale(Sec.apply
to a now and f property
Code:The Contractors Lienee Law
q$S does not ap ch torn owner of p rough who Wildsori es,provided
that
and - OCC.GROUP RES..UNITS
whoovdoes
mentsa not or
his own e.If,however,thebuildisuch dp
improvement usold t intenoneoarofc=rofficred car Male.ILer- flder ilIhaveng or TOTAL: -
improvement bsold withinoneyearo(completiogeheowner-bu0derwill have
s the4urden of proving that he did not build or improve for purpose of sale.). QTY: PLUMBING PERMIT FEE- - FLOOD WNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
v
1 contractors to construct the project(Sec.7094,Business and Professions Code: �—
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or improves thereon,and who contracts for such ptojects with a -< FEE.SUMMARY
co,�nt[[act(a)gcensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
IJ I or erept under Sec. B k P C for this reason
OUTS I DE FEE 5
.ex DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y N_
` Owner - Date RECEII'T X
WORKMAN COMPENSATION DECLARATION FIXTURpg PER TRAP ' -OJ SCHOOLTAX Y_ N_
91 hereby affirm that I have a certificate of consent to self-inure,or a �� RK—UPT X
certifimteofWork mCompemaHonluumnmo acertifk mpythemof(Sec' GAS F.A.SYSTEM-1 INC.40UTLE75. - PARK FEE Y N
350QLab C.) hC� 076 2? RECETT
PoliryX S•1'N�•e -jr J GAS EA.SYSTIM-OVER4(EA) -
Com any � BUILDING DIVISION FEES
Certified copy ishereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR 'PLANCHECKFEE
certined ropy Is Rled wafh the city Inspection division. �j fir(
CERTIFICATEOFMMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F7. d Rett`i [#
ffhis section need not be completed if the permit Is for one hundred dollars
($100)or less) - WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
Icertify that m the perfor anm of the work forwhich this permit is Issued, �:O•
1 shall not employ any person in any manner so so,to become subject to the WATER SYSTEM/TREATING -
workeriCempensationlawMofcaufomia.Date PAID- LI 13—
O Z Applicant NEWRESIDENUAL PLMB. Q.FI. Date to el t#
Z O NOTICETO APPLICANT.11,after making this Certificate of Exemption,you
N should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such provisions orthis permit shall be
_ deemed revoked. BUILDING EEE
_W �} CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Ihereby affirm that there isammtruction lending agency for the perform- 9 ELECTRIC FEE oc
Z ante of the work for which this permit Is Issued(Sce.3097,Civ.C.) TOTAL:
00 LenderMName PLUMBING FEE ao
F LdAddress - QTY: MECHANICAL PERMIT' -FEES a�
LL eners MECHANICACFEE _ �^
U nmet.l�Aiftagreet comply withalicitynand dcountetorahs above information p
O ID Isctingt building comply all<Ityanyautho empocesand Mate laws PERMIT ISSUANCE FEES ip/
U• city toenterupongeabcov Rton, oredprop authorize representatives of thIs
H N cityWenteree to sae,indemnify an
property(grunge Cit purposes. ALTER OR ADD TO MECH. dJ
? (We)agree to save,indemnifyyse a keep harmless the City y Cupertino Date _ ReOTAL
O against said City tenielacer the
expenses whish mayinanywayaceme AIR HANDLING UNIT fro l0,tX10 CFM) $UBTOTAG
agaimtsaid(:ity in consequence of the granting of this permit
AIR HANDLING uhnr(OVER lB,ogocFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date E(HAUSTHOOD(IN/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE t
Will thea applicant or future building occupant store or handle hazardous HEATING UNIT(70100,000 BTU) ,
PP B P Date �ReCei t#
material as Safety by the Code
Municipal Code,Chapter 9.12,and the - o
health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑Yes M No
VENTILATION VAN INGLERESID
wm B,ea applicant err contaminants
occupant useequipmentmem or demes' (5 ) ISSUANCE DATE
which eManage ent atrrict? nanbasdelvedbythe'BayArea Air P�
Quality Management District? '. BOILER-COMP(3I-R'OR 100,0(p BTU) .luta® -
4have read the hazallousmmaterlals rcquircments under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 5.1991
the California ldealth k Safety Codq Sectors 25505,25533 and 25534.1 AUG�r77
understand that if the building does not curently have a tenant,that it is my� NEWRESIDENI]ALMECH. SQ.I7.
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy. - �`� �
Owner or authorised agent Date TOTAL: ISSUE
OFFICE COPY