21550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
Building Projeo Identification 7 PERMIT NO.
Building Address:
l 444 Hc9o-tSbTF-�kD `t 21550
wMrSNams: Ph... APPLICA I IUN mJIJMi I A A IL
�Q-1 �-L E CITY OF CUPERTINO-BUILDING DIVISION
ContraName: Lic.N.
CR APPLICATION I PERMIT
J 13 BUILDING-ELECTRICAL-PLUMBING-MFiCHANICAL CATEGORY CONTROL 0
Architect/Engineer. Lic.Na:
C QTY ELECTRICPERMIT FEE BUILDINCPERMITINFO
Address: I PERMIT ISSUANCE I ❑ ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebySection 7000) f Chapter AI'PLIANCESRES[DENITAL JOB DESCRIPTION
Ing with Section7000)of Divlelon3 olthe Buslnessand Pro(eselomCode,and my
license Is I.Full 1!`fg. PANELS
hem. Chic_llI
Data Contorract
ARCHITECT'S DECLARATION 201-1 DJ0 AMT'S
pqqP±±re0 7777 I understand my plans shall be used as public remMa OVER 1000 AMPS SQ.Fr.FLOOR AREA � S/SQ,FT.
E E Licensed Professional SIGNS ELECTRICAL
�<<¢� OWNER-BUILDER DECLARATION SPIiCIALC1RCNr/MLSC
I hereby affirm that I.exempt from the CoMracmrs License Law for the
following reason.(Section 7031.5,Business and Professions Cade:Any city or
mntywhich requireia permit tocorrtrud,alter,improve,demolish,orm;eur TEMP.METER OR POLE INST.
anystm=mpdortolbf ance,aLwrequi theappli-ntforsuchpermitto POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
3wG Contractor's License IAW(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRO
0 sion3ofthe Business and Professions Code)or that he is exempt therefrom and VALUATION
(he basis for the alleged exemption. Any violation of Section 70H.5 by any Q f
ppliontforapemtaubiemtheapphcanitoadvilpenaltyanotmmtMn UTLETSSWITCHESFIXil)RFS ! `•(pL)
five hundred dollars($500). NEW RESIDENTIAL ELI?CTR
g Z�O n I,as owner of the property,or my employees with wages as their sole 51'ORICS TYPE CONSTRUCTION
compensation,will do the work•and the struclum is not Intended or offered for
O
sale(Sec.7044,Business and Profembre Code:The Contractors License Law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RFS.❑NT[S
who docs such work himself mthrough hi.own employees,provided that such
ImprovemenGa notintendedorofferedforsale.If,howevegthebuildingor TAL:
Improvement lased withlnoneyearofcompldiogtheowner-builderwlll have
1 rden of pmving that he did not build or bnprove for purpose of sale.). QTY, PLUMBING FEE --TED OZONE APN
f as Owner of the property,am exclusively contracting with licensed PERMTT ISSUANCE
--tractors to-rut-d the project(Sec.7044,Business and Professions Code: /
The Contmdor's Licerae Law does net apply to an owner of property who ALTER D &VENT W
Wilds or Improves, thereon, and who contracts for such pjojem with a
CQBtI etmala)licensed pursuant to the Contractors License Law. BACKFLOW OTGCT. E FEE SUMMARY
LJ I am exempt under Sec. B&P C for this remon
Owner Date DRAINS R SANITARY RECEIPT-
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a cedifcate of consent to self-insure,or a ETXTURES SG-100L TAX Y N_
-difiateofWark Compere tionlmumnceoracertified-pythereof(Sec. RECEIPT
3800.Lab C.) C.a O GAS EA. - C.40 EI5 PARK FEE Y_ N_
PoliryN c7V/'�PT�F�/L�L�
RECEIPT It
Com GAS EA.SYS - ER 4(FA)
ertlhed copy is hereby fumlahed. BUILDING DIVISION PEES
❑CrAllied copy is filed with the city inspection dlvlsm., GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(I'hissedlOnneed nat becompleted lithe permit laforonahundnA dollars SEWER-SANITARY-SIORM EA."Fr. Date Reeei t#
($100)orlcaJ WATER HEATER W
]certify thatthe performance Of thework forwhich Ithe /VENT/E•ECTR ENERGY FEE Y N_
—
1 shall not employ
to y any person in any manner so es to become subject to the
Workers'Compensation Gore of California Date WAIi]i SYSTEM/TRGA]ING
0 PAID
Z Applicant
Z NOTICE TO APPLICANT:]f,after making this Cer irate of Fiemption,you NEW RESIDENTIAL"B.__SGL T, Date Recei t#
Fshnuldberomesubjcc<to the Worken'ComperuaUon provuloro o(the Labor .
WN Code,you mustforthwlth comply with.uch provisions orthis permit shallW TOTAL:
> deemed revoked. BUILDING FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaf0rmthatthem b a coumctlon lendingagenry forthe perforrm TOTAL: ELECTRIC FEE p
Z ante of the work for which this permit b issued(Sec,3097,Civ.C.) 4
U O Lender.Name PLUMBING FEE
LL h- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icem(ythatlluvcread this application and slatethatthe a boveinformatton
IL beomel.Idgree to comply with all city and county ordinances and gate laws IPERMTTISSUANCE FEES PAID:
} N relating to building-mtmetion,and hereby authorize representatives ofthis
F Z city to enter upon the above-menloned property for bupedion purposes, ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
agaWt lla luti��sjodgments,cons and expenses which may In any wayacclue AIR FIANDiJNG UNIT 10,ODO CFM) SUBTOTAL:
agalnat aai [y In-n of the grant) g of this permit.
AIR HANDLING UNIT(OVER 10,000 CRM) CONSTRUCTION TAX
sigwmr (App�cent/Contract0-----C Data EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wiil the applicant or re building occupant store or handle hazardous HEATING UNIT VD,W0 BTU)
metedal as defined by Cupertino Municipal Code,Chapter 9.17,and the _ Date ReCel [#
f]❑Ynd Safety Code,Sen 75532(a)7 HEATING UNIT(OVER IWilixI BTU) TAL• r71
Will the zppllant Or fumrcbuildin9 Occupant use equipment or devicesF�JLFR-GOMP(OVER100,00013TU)
(SINGLE RFSID) 1$ ('1 CE-DATE
which emit hazardous air coutamlwnts as defined by the Bay Area Air
Quality Marugcmcnt District? OR 100,MD BTI-
4 Yea fin'No I J�76I
have read the hazy ou.materials requirements under Chapter 6.95 ofR100,000BTU)the California Health&SA(dyCode,Sections 25505,75533 and 75534. I
understand that ifthe building does not currently haveatenanL that llkmyMEIN. SQ.FT. Mel
Me�dfrso
responsibility to notify the ompant of the requirements which most be met 1CdV�SFA lNsas^4,Isssap
prior to issuance of a Ceraflcote of Ompanry,
Owncr or allthOdmd agent Data ^�4p ■�
TOTAL: ISSUED BY:�yTi�QYI�QECJCC-i
OFFICE COPY