21503 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification _fkePE WT NO.
Banding Ad :O s� c ' �"�" 21503
one: _A=777 A
R. C 45--yt/ V.24 CITY OF CUPERTINO-BUILDING DIVISION
Contraaor'a Name: Lk.Na: APPLICATION /PERMIT �--30- O`
OW BUILDING-ELECTRICALPLI)MBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addres
1'Qth9TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am hormad under provisions of Chapter9(commenc - APPLIANCESRESIDENDAL JOB DCSCRET70N
i1.1 in
force and effect. fthe Businessand ProfessionsCode,and my
L"--"le fo fun fora and effect PANELS
License Class Llc.p
Date Contractor —UP TO 2DO ANTS
ARCHITECTS DECLARATION 701-1000 AMPS
9z Iuodergand Tans shall be used public records. OVER 1000 AMPS
O Q rr7 P W SQ.FT.FLOOR AREA $/SQ.FT.
LL+�
Licensed Pmfeffibwl SIGNS ELECTRICAL
�6a OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
f'yd.7i IherefR
byarenthat lamemmpt fromthe Contractor's Ucense Lawforthe
following reason.(Section 7m15,Business and Professions Code:Any city or TEMP METTROR POLEINST.
0- following
countywhichrequlresapermittommtmmc ter,Impmve,dennle,h,orrepair
anystrucwre priorto its leuance,aise,requirestheappllcant for uch permit to POWER DEVICES
a file a signed statement that M e,licensed pursuant to the provisions of the _
�3wG Contractors License law(Chapter9(commencingwlthSection 7000)ofDlvi-
f,�0� sion3ofthe Buslneaarad Profealoru Cedgorthat hee,exempttherefromanl SWIMMING POOL ELECTRIC VALUATIO
•- the base,for the alleged exemption. Any violation of Section 70X5 by any O
applicant fora permit subjects the apPlkant to a civil penalty of net anre than OUTLETS-SWITCHES-FIXTURES OOs Q
five undred dollars(S.SOO. NEW RESIDENTIAL ELECTR JJ
j< 1,as owner of the Property,or my employees with wages as their sole SQ.FT. SfOFUES TYPE CONSMUCTION'
compemation,wllldothe work andthemmmm e,not intended or offered for
O ale(See 7'OK Business and Profession,Code:The Contreeme,License Law
docs not apply to an owner of property,who builds or improves thereon,and
0.0. who docesuch work himself or through hisown employees,provided that such OCC.GROUP RES.IMITS
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within no yearofcomplelon,the owner-bullderwill have
thLburden of proving that he did not bund or Improve for purpose of ale.). QTY. PLUMBING PERMIT ---
FEE }TROas owner of the property,am exclusively contracting with licensed D ZONEPERMIT ISSUANCE APN
m
contractors construct the project(Sec 70K Business and profa Blom Code:
The Contractor's License Law docs net apply to an owner of property who
builds or Imp.thereon, and who contras for such plojALTERects with a DRAIN&VE-NT-WATFR(EA)
C.6'eter(s)Bansei punuamtothe Contractor'sLkxnae Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. -B &P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT P
❑1 hereby affirm that I have a certificate of consent to self-Inwre,or a MNRESPER TRAPSCHOOLTAX Y N
cealflcate of Workea'Compematlonlruurance ora certified copy thereof(Sec. RECEIPT a
3800,LabC.) GAS EA.SYSTEM-1 INCA OITILEIS PARK FEE Y N
lla Y RFCF.ExI'a
CoCm ray CAS EA.SYSTEM-0VERd(_A) BUILDINGDIVIBION FEES
�]Certified copy b hereby famished.
OCeaved copy Is filed with the city inspection division. GREASE/WDUSTRL WASTE INTFRCFP7OR PLANCHECK FEE >
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 3tZz
COMPENSATION INSURANCE SEWER-SANTfARY-
(TBIsslon need not Mcompland lithe permit e,forone hundred dollars STORM FA.200117. Date Recei t#
M
(81I camlea.) WATER HEATER W/VENT/ETECTR ENERGYFEE Y N
I ll nor that N the pe a..race any
cr work for which the,permit c to th,
I shall not employ any person in any manner so a to become subject to the
Worlicant mpensatlon Laws o(Gllfomia.Date WATQt.SYST�M/7REAT1 PAID
O Z Applicant
Z O NOTICETOAPPLICAM:IL sleet making the,CertBkate of Ezemptlon,you NEW RESIDENTIAL PCMB. Date Recei t#
Hshould become subject to the Warken Compensation prove,lom ofthe Labor TOTAL:
LUN Code,you must forthwith comply with such pvkioor this permit shall be
> deemed revoked. rom BUILDING PGE
IL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I herebyaffirmthatthem iaacomtruction lending agency forthe perform
once of the work for which this permit is Issued(See3097,Civ.C.) TOTAL: ELECTRIC FEE
U lender'sName PLUMBING FEE
IL H Lenders Address QTY. MECHANICAL PERMIT FEE
0U 1 tertifythat l have read the,application and statethatthe above InformationMECHANICAL FEE
incorrect.I agreeto comply withal]cLLyand county ordinances and state laws PERMITI.SSUANCE FGESPAID:
>. W miatingtobuildingmmWMon,and herebyauthoriureuesentatlemofthe,
1— Z city to enter upon the above-mentioned property for int Ion purposes. ALTERORADDTOMECH.
U — (We)agree to ave,Indemnity an a keep harMea tha C of Cupertino Date Receipt#
agaimt llabWtka,jrd,rng.%cmt and ex pensnewhichmayin. ywayaame AIR HANDLING UNIT(To lo,"CFM)
agaimtsai incon u n o gra gofthis it SUBTOTAL:
AIR HANDLING UNIT(OVER I0000CFM) CONSTRUCTION TAX
Ig umof pliant/Contra or Date EXHAUST HOODgHEATING
W/DUCT) CONSTRUCTION TAX PAID:
HAIR R DOUS MATERIALS DISCLOSURE
Will the applies rat or future building occu pant store or hand le haurdous UNIT 00 1 W,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date RCcel t#
I Icalth and Safety Code Season 15532G)7 NIT(OVER 100,000 BTU)
F1 Y. r]No TOTAL:
Will theappliant orfumrc building oavpantuxequlprrcnt ordevicesN FAN(SINCLE RESID) ISSUANCE DATE
which emit hemmiceus air roma mataraas dented by the Bay Area AuQuality Management District? PO]-I 100,IXD BTUs4 Yes 4 Nahave readtheh.r ousmaterials requirements under Chapter 6.95 ofP(OVER 100,000 BN)
the Glifemia Health&Safety Code,Sections 75505,25533 and 7SS3d.I understand that lithe building does not arrently have a tenant,that it is myNTIAL MECIi, SQ.FT. Fps •"'Y"
responsibility to notify the oc.p.rt of the requirements which must be met
prior to issuance of a Certificate of Occaps ncy.
Pvner or authonud agent Date h�"its_"?py
TOTAL: ISSUEDBY: 'k/ -B`1�`
OFFICE COPY