21289 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idemifiealloat /n a(�� PFI MIT NO.
`) Building Address: - _ V �l 21289
/1 /1/"5
r Crj I?F_SS f 6 1• G 28
Owner. ane: one; p
assn ratlnr@N. CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT '
BU LDINGfl.ECTRICA4ML BINGMEC}LANICAL CATEGORY CONTROL X
Architect/Engineer. Lk.Nce
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PFRh9TIS5UANCE ® 1:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby n7Othatlem licensed oftunder provisions
andPro Chains 9(wmmmc APPLLANCESRESIDENTfAL JOB DESCRIPTION
ingweh In fon force and
effect. ofthe0usiwmand ProfemlenaCadeand my
Li...I.In full force and effect. PANELS /
Llcenm Clam LILY l0 �WV
Dale ContractorUP TO 200 A
ARCHITECPS DECLARATION MI-IOW AMPS
Z 1 understand my plane @hall be used m public records. OVER 1000 AMPS SQ.FT.FLOOR AREA F/SQ.FT.
O
k� Licensed Professional SIGNS ELECTRICAL
<<6 OWNER-BUILDER DECLARATION
)n SPECIALCIRCUIT/MISC
Z i (hereby afirrnthat l am exempt from the Contractors Licenm law for the
following resson.(Section 70715,Business and Professions Code:My city or
TEMP.METEROR POLE INS(.
�� countywhIchctoue reguiresatings Iermitta aisoreat,a)t es theapmvntforsch,ormpair
to
any atsucturc prinstatement
that
he is licensed pursuant
to the pro suchofpermit e POWER DEVICES
0 5 Bis a signed statement that he b licensed pursuant to the provision of the
1„�O}u.F Contractors License Law rafeanumCod )orthatmencing with xempithection 00)of Divi- SWIMMING POOL ELECTRIC VALUATION
ebn3o(the Bueincse and PmfembmCode)orthrt help exemptthere(romand �T
¢...•3333 the basis for the alleged exemption. Any violation of Section 70)15 by any OVILEISgWITCHESFl%TURM
{g�' eppH.tforapermitwbjndstheappncenttoacivflpenaltydcotmorethan
ndred dollam($SOfB. NEW RESIDENTIAL ELECTR SQ.FT, WES TYPE CONSTRUCTION
GWWW1 �n as owner of the property,or my employees with wages as their wle
c Ve Nnsadon,w0ldothe work,andthestructure isnot intended or offemd for
Oe(Sec.7046,Business and Pr femiom Code:The Contractors License Law
$ docs not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
whodoeseuchwork himselforthrough his own employees,pmldedthatsuch
Improvements are not intended oroffered for sale.If,howeveq the bulldingnr TOTAL:
Improvement Iswldwithln omrarofcomplmiorytheowner-buMerwW have
tl,kurdenof proving that he did not bund or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
UL as owner of the property,am exclusively contracting with licensed 17-OOD TONE APN
contraciorstocomtruct the pro)eit(Sec7044,Businemand Professfom Code: PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of property who -
bunds or Improves theeon,and who contracts for such pkujecis with a ALTER-DRAIN&VENT-WATER(EA)
aHo.cu rW licensed pursuant to the Contractors Llmnm Law. FEE SUMMARY
U I am exempt under See. 0&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FErc
Owner Data DRAINS FLOOR ROOF,AREA,CONTI. SANITARY . Y N
. WORKMAN COMPENSATION DECLARATION - RECEIPT X
Of barely affirm that I have a certificate of om,u nt to selLm
lnsu ,or a FIXTURES.PER TRP SCHOOL TAX Y N
renifiowof Workera'Compematlmn lmumnm macenlfied copy thereof(Sec. RECEIPT Y
3800,Lab C3 GAS EA.SYSIFM-1 INCA OUTLETS PARKFEE Y_ N_
Policy RECEIPT X
C.9i. GAS EA.SYSUM-OVER 4(EA)
cra�mpany PLANCHECK FEE
DIVISION Fees
I ICeniOed copy b hemby tum a city GREASE/INDUSIRL WASTE INTERCEPTOR
I�J-r Cenffied mpy b flied with the city Wpectbn division.
CERTIFICATE Of M(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA?INLET Date RMei t#
(This @ration need not be completed I the permit b forone hundred dollars
(SIW)ar lam.) WATER HEATER W/VENT/ELECTR ENERGYFEE performance _
I unify that in the performance of the work for which this permit is Weed,
I shall not employ any person in any manner an as to become subject to the WATER SY5TQP4/TREAUNG
Workers'Compensation Laws of California.Date PAID
Applicant Date Recei t#
Z Z NOTICETO APPLICANT:If,after making this Ceriflcete of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT.
should become subject to the Workers''Compemation provision of the Labor TOTAL:
tlT Code,you must forthwith comply with such provisions orchis permit shall be BUILDING 1�
W ] dermad revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE L"
M e I hemby afflrmthat there b a construction lending agency forth@Nriorm, ELECTRIC FEE
M Z an ofthe work for which this permit is Issued(Sec.3097,Civ.Q . TOTAL:
02 I.ender's Name PLUMBING FEE
LL F Lender's Addmss QTY. MECHANICAL PERMIT FEE
O W I certltythatl have read thbapp0otlonund statethattheabove Information MECHANICAL FEE
S Is correct.I agree to complywlth W etyand county ordinances and Mate laws PERMCC ISSUANCE FEES PAID:
>- 0. tobullding construction,and herebyauthorlaerepresentativesafthb
I- N tltytoenterupontheabove me aned property(m impetllon purposes. ALTERORADDTOMECH.
? (We)agree to save,rode end keep harmlem the Clty of Cupertino Date Receipt#
V agaWtllabNtles,IsdE rate, arW expenaee which nay In anywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agabat aid It. c sae c ofthe granting&this permit.
/( AIRFfANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX Q CONSTRUCTION TAX PAID:
Signature of ppll rat `o ra D— ate - E%ITAUST Fi00D(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will theappbontorfuture building occupant store or handle hazardom HEATING UNIT(TO 100,000 BTU) Date RL'cel t# I SO
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea b No
Will the applicant or Solon,building occupant use equipment or devlers VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous a4 contaminama as donned by the Bay Area Air Pn AIr�
(N Ilty Management District? BOILER-COMP OHP OR 100,000 BTU)
4Yn No
h7madthehecaracusmalerialsrequirementsunderChapter6.95of WILER-COMP(Ova 100,000 HIM Ori � � to
the Califomla Health&SafetyCode,SMlom 25505,25533 and 75534.1 b la913
understand that lithe building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECTL SQ.FT
rmpr to Issuance
of a Certificate
of oftherequiremenlawhich moat 6e met at Y& , _ Q
prior to Wuaner ofay the cau occupant
thenry. a(asiaa�snt@FI���..��( GVp`�\+a9` rY.�l
Owner or authorized agent Date ISSUEDBY: P " - ---
TOTAL:
OFFICE COPY