20978 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: 2 O n 7 8
21d23C'iNt�IST�SEM1I DR • G J
nen one;
Nd BIAS /mss CITY OF CUPERTINO-BUILDING DIVISION C) —Qct
t°d9r Na""' Ne; APPLICATION / PERMIT
- BLRLOINGELECnUCALPMU BINGMF LAICAL CATEGORY CONTROL#
•.. Arrhitm/Fsgbwer. Lie.No: -
1 Yeo!Wfn "4 7/ ZI BUILDING PERMIT INFO
- QTY ELECTRIC PERMIT FEE
Address 2�0(p/ 'RoL ea MVI PERWTISSUANCE _QDBILD � C] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRBaDOfy
Inense 1.1.fors force afd effeon3o(NeBuair,esandProlndonaCode,andm �l_'�j�`,
license Isins force and e.N PANELS ( F'� tC.'1B�'�} / (d14
Limns Chs LIoY �
Date ConhactorUP TO 20EIAMPS
-
XII-IOW AMPS
µQ�9O Zp I e an ns I u bBc Tsorda OVERIWOAMPS SQ,FT.FLOORARFA
E d(/ Profeslo r SIGNS ELECTRICAL
d� u O ER-BUILDER DECLARATION $I'[CIALCBiCUIT/INLSC
Zf j' Iherebyaffi R.exempt from the Contractors License Law fee the _
0gp qqqq following reason.(Section 7031S,Business and Profession Code:My city Or
countywhi6rNuiresaperentwcomtmct,alteolmpmv de=lWh,orrepair TEMP.METFRORPOLE INST.
eN°� any structure Eumoto itslsuance,ala°requlreatheappileam forsuch permit to . POWER DEVICES
�o. file•signed statement that he Is licensed pursuant to the provision of the
Contractor's License Law(Crepter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC UA
SOS don3 ofthe Businmsend Profeslon Code)orthat he b exempt therefromand VALTION
a, the basis forthe alleged exemption. Any vloIdkm of Section 70315 by any OUTLFTSSWITCHES.HXTURES Ca!
appLimnt fora permit mbjedstheapplfcant too dW I penalty a net moretMn
five hundred dollars(SWO),
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION'
p perry,or he employes with coders ea there rule
com(See.7KBuldotheworkanddomCde: bawlIntended oroffered for
O sale(Sec.apply
to an essow and f property
Code:The Contractors Limns law
dmsout
uessucytornownrofproughhisonemsarlmproovidedmrythat uch OCC.GROUP RES.UNITS
0.0.
who
provementsan khimself dedorwgh hisowne.If,ho evertdedilding r
Improvement'red withendedearofredlm alNthe owever,thebuiWingm TOTAL: Z s
improvementismld colthlnoneyearofcompldlorytheowner-WLiderwllhave
tl(pjZvden of pwWng that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed HOOD ZONE APN
contractors to construct the project(Sm.70K Business and Protrusions Code: PERMIT ISSUANCE
Tlw Contractors License Law don nM apply to an owner of property who ALTER-DRAIN&VENT-WATER 11N
Wilds or improvn thereon,and who contracts for sueh pzpjmx,with a FEE SUMMARY
cYp)Tacror(s)Licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B&P C for this reason
Owcar Date
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
REC=Y
WORKMAN COMPENSATION DECLARATION FIXTURES.MR•TRAP SCHOOL TAX Y_ N_
^dI hereby affirm that I have a mrtifiate of consent to self-Inwn,or a
certificate of Workmen Compensation Insurance ma cartified copythereof(Sec. RECEIPT N
3800,Lab C.) CAS EA.SYSTEM-1 INCAOUTLETS PARKFEE Y_ N
Policy N RECEIPT M
CmaAS F.A.EA.SYSTEM-OVER 4IRA)
BUILDING DIVISION FEES
Certified copy Is filtd.
CertCREASE/INDUSPRL WASTE INTERCEPTOR PLANCHECKFEE ep��
Certified copy b filed
with
the ten city Inspection division.
CERTIFICATE OF EK'EM FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XIOFT Date Recei t#
(Thissection need not be completed Lithe permit b forone hundred dollars
($100)mlem') WATER HEATER W/VEM/n cr•TR ENERGY FEE Y N
I certify that In the performance of the wmk forwhlch this permit is issued,
I shall not employ any person In any manner so�s.tP.bemme Ibje}}Jj.jjyy WATER SYSTEM/TREATING
Worked Coma !California Date P¢� E[7t PAID 6
0 APplic s==-! Date RLroei tN
Z 2 NEW RESIDENTIAL PLMB. SQ.FT. -
O NO CE 0dbeco sub he ager making rs Compensation
Certificate is Exemption,you
should become subbed to the Workers'Compenatlon provision of the Labor TOTAL:
Code,you must forthwith comply with such provision orthb permit shall be
LU > deemed revoked. BUILDING F D 0
CONSTRUCTION LENDING AGENCY - IE
SEISMIC FEE
Il C Ihfthe work for at which t bacontmctlontnSec.097,agencyCi(orthe perform- ELECTRIC FEE
Z anceofthe work for which this permit bbmed(Sec.3097,CIv.CJ TOTAL
LL O Lender.Name PLUMBING FEE
ly F Lenders Address QTY. MECHANICAL PERMITMECHANICAL FEE
O W Imrltfythat Havemply with
aBmtb and
countethattaums and date
a bmrmat.I'greetocomplywith andtyaM couhorize epresaand rtatelaws PERMIT ISSUANCE FEES PAID: 6
>. N city to
entrclattogtobuilding contmttton,andhereby opertyor Inspection
n reprexntativespurpos o(thb ,3
dl ( enteruponto save,
indemnify an d propertyforWpe Cit,purposes. ALTER OR ADD TO H.
Z
(We)agora m save,Indemnlly an d keep homeless the Cit,of Cupertino Date � Reeei tN
V against LiabWtlea,judgments,cortsend expenses which may In anyway acerae AIR HANDLING UNIT(TO 10,000 CFM), SUBTOTAL:
'Saint aid City In sen ence of the granting a this permit.
i' 7; AIR HANDLING UNIT(OVER 10,000CFM)
CONSTRUCTION TAX
/ D
rig fit ontmctate EXHAUST HOOD(W/DIX:T)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT DO 100,000 BTU) Date Recel til
material a a defined by the Cupertino Munidpa l Code,Chapter 9.1 2,and the - -Health and ion 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
YenNo
mallis applicant mLure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent havardous air contaminants as defined by the Bay Area Air -
f QaalityMarugemenI ct7 B
OILER-COMP DHP ORI00,0(DBTU) PAID
4Yn No AI
havereadtheF, a ausrtuterialsrequirementsunderChapter6.95ofOILERCAMP(OVER 100,000BTU)
the California Health&Safety Code,Sed ion 255D5,25533 and 25534.I SEP p�
understand that lithe building does not currently have a tenant,that it b my SEresponlb0ityt notllythe the requirements which moat be met � ,
prior to ua e f NI sof panty. _ fv
ncr or aDate ISSUEDEitd
ulh gent
Q-S- TOTAL:
OFFICE COPY