21654 APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect identification PERMIT NO.
Building Addn..: -
9,03-74- 21654
cl � Fe � � � �
nera ams: one:
.25a03),- CITY OF CUPERTINO-BUILDING DIVISION /b�Q
Can anar)Name: LIc.Nm APPLICATION /PERMIT [ I
W / I Aari E-9,.TLti Af q'G 5'7 U S
BUILDING-ELECTRICAL-PLUMBINGMFOHAMCAL CATEGORY CONTROL«
Architect/Englwer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICF.NSEDCONTRACTOR'S DECLARATION O ❑ ElY
I hereby affinothat l am licensed under provisions of Chapter9(cxx.,. APPLIANCES-RESIDENTIAL, ]OB DESCRIPTION
Inense I SeMon 7000)a(Dlvielon3ohhe Busineeaand ProfypploneCode,and my
license Is In fu fo;pe d dfect. PANELS
License Ciars « t LM.N '� J`7 L/ e7
Date N Contractor ti q9,-`, UP TO 200 AMPS
ARCHITECPS DECLARATION 201-IODDAMPS
pia rcO z 1 understand my plam shall be used as public remNa OVER IWD AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
Ft (a Llmnsed Prole®local SIGNSELECTRICAL
«<<� L61 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
p, F, Iherebyafflnnthatlamexemptfmmthe Contractors Llcvnm IAwfmthe
7 following Ingreason.(Section 7031.5,Bodine..and Profenlone Code:Any city or
r can whichr uIreapemttomulu altermprovgdemlbh,orrePait
-TEMP.METER OR POLE INST.
�e any.tlatcd mumu It that a is licensed
pursuant to the provisions
of t e POWER DEVICES
K floe..igned Rcens eLa that he t Ilcemed pursuant it the provbWm of the AF
Oµ Contra&3ofthaLlcense d(Ch.pre.C( e):enting rihthelh SeHon 7000)tthemfof Divi.
mand
;O slon3o(the Buslnoawd Protemloru Code)orthat hebeumpttherc(romend SWBrthONG POOL ELE C VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OITILETSSWITCHES
applicant fora permit wbjectstheapplicant to a civil penalty of net nitre than
five hundred as
ewner of the pr. NEW RFSIDFNTI ELFCTR .Fr. STORIES TYPECONSTRUCTION
�n ❑a es owner of the property,or my employees with wages as there cats
t mm(Sac.7K Busio the ness
and rkand lheas Cdurebrotintended Livens Lfor
5 O dile(Sec.apply
to aniesa and f property
Cade:The Contractors hemon Law
r3$ does not applytoanownermpropertywhobuilds orlekpm ithereon and OCC.GROUP RES.UMTS
whodaementsworkhimselfed orough hlaor e.It how0.provMedhe ildig or
Improvementsarecal intended earofcdforsale.thh ner-p gder building have
Improvementbwld wilhlnoneycara(complctbn,theowner-bugderwlll have
the burden of proving that he did net build or Improve for purpose ofmic). QTY, UMB PE T t I FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMITANCE
contnctan to coastrud the project(Sec.7044,Bu.m.and Profe.slom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRA &V (EA)
builds or Impraves thereon,and who contra far ouch ptojem with a FEE SUMMARY
mg)jacior(s)Bcen.ed pursuant to the Contadoes License Law. BACK FLOW!WT.DEVICE LJ I am exempt under Sec B k P C for this reason
Owner Data
DRAINS FLOOR OORECEPr M
F,AREACOND. SANITARY Y N
.
WORIt'MAN COMPENSATION DECLARATION FUCNRFS PER SCHOOL TAX Y_ N_
❑I hereby affirm that I have•certNate of consent to eeRue,
-Inrora RECEIrr M
mdlficateofWarkm Compematimlmuranmoramdifiedwpythemof(Sec. CAS EA.SYSTEM-1 WC.40I1TLETS PARK FEE Y N_
3800,lois )
Paley« alba?rs3e �g� RECEIPT
GAS EA.SYSrFM-OVER4(EA)
Com env ,4)"A uti BUILDING DIVISION FEES
�Cedlfied copy b hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-sAMTARY-sroRM EA.2f10HT. Date Recei t#
(Thl.wdianneednabecompleted Blheper tbforomhundreddollen
WOO)a,tess.). WATER HEATER W/VENT/FT.ECTR ENERGY FEE Y N
I ceH(ythat b the performance o(the work forwhich this permit Is ed,
I shall not employ any person in any mwner w as to became subject to the
O WATER SYSTEM/TREATING
Workerx'Campc.W1..Lawsof C.11fomla.Data PAID
Z Applicant NEW
Z O NOTICE TO APPLICANT:If,after making this Certificate PLMII. SQFC. Date Repel [#
te of Exemption,you
should become subfeet to the Workers Compewtion provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions orthh permit shall be _
13UILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a cowtmetion lending agency for the perform- TOTAL:
ELECTRIC FEE
O anceo(the work for which this permit Mw
eed(See 3097,CIv.CJ
V 4nderi Name PLUMBING FEE
H Lender'.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
leformintlese
O W Imdifyahatlluvereply withal]
notatyratle...and
Asia 1.
�a�s
G bcorrert.building complywo,alndtyand muntyise repnceaand Ratelaws PERMIT ISSUANCE «„CYC FEES PAID:
ing to building
hereby
r W cityrelatoanter.prot the
o bove- attioddproprty authorisetatives
FZ citytoenteree to lhe,indemnifyaned propeetyfor mte Cit purposes. ALTER OR ADD TO MECH. - Date Recei t#
V _ (We)agree to rave,Indemnify an d keep harmless the City of Cupertino
aaWllia tie;judgments,mrtaa expenseswhkry
h may any wayacctue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:S
ago dCity In con a egranting of this permit.
Q^Q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S1 reel Applicant/Contractor Date EXHAUSTHCOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous f' HEATING UNIT(TO 100,000 BTU) ' �(� Date Recei t#
material as defined by the Cupertino Municipal Code,Chapler9.12,and the
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑YenNo
Wllltheappllaen or uhrebullding occupant use equlprrent or devices VEMILATIONI°AN(SINGLE RESIT)) 4
tea[ NCE DATE
which emlt havedous air canbminanls as defined by the Bay Area Air r
Ou silty Management District? BO[LER-(.COMP 0H POR 100,OOD BTU)
Yee ❑No Np{ p o l]
have read the haxandous materials requirements under Cha Ater 6.95 of BOILER-COMP(OVER 100,000 BTU) �B'f�s11 ✓�a�a
V the Gltimes Health A Safety Code,Sect lam 75505,25533 and 25534.I ¢\'^
understand thatif the building does nor currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFr. � ^-�'
reaponsibllity,to really the Occup.at of the requirements which must be nort A" t!d
prior to Issuance of a Certificate of Occupancy. F�,.`cl}^"
Owner or aulhodud agent Data ISSUED B
TOTAL:
OFFICE COPY