21013 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
-
Bull gAddres=: nn e 21013
O cn�'w o o car Iw>•t. •.: ".: -
I
ante: A rxn__ one: - A
Iev�3 Aa M,61_02 70 CITY OF CUPERTINO-BUILDING DIVISION q f l
nntadm's Name: ^LIc.No: ' APPLICATION:/PERMIT
BUILDING-ELECTRICAlePLUMBINGMECHAMCAL CATEGORY CONTROL Y
ArcFimct/Engineer. Lle No: -
CITY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
AddrcacPERMITISSUANCE v� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapler9(cammrnc APPLIANCESREADENTIAL - jut,DESCRIPTION
h 7000)oflelon3 oflhe Buslnessand ProfeulonaCode,and my
he".se
irgwJt Slefucctiollllforceende
ffed. " PANELS
License Class Lk.Y
Data.. Contractor " LM IQ 2DO AMPS
ARCHITECTS DECLARATION 201-1000 AMPS -
µpp�u!a0 O I understand my plana shall be used as public records. OVER 1000 AMPS SQ.F1 FLOOR AREA 5/SQ.FT.
Eod0���uuu Licensed Professional SIGNSELECTRICAL
<< OWNER-BUILDER DECLARATION = 9eEC1ALCBtCNT/MLaC
i.., Iherebyafflrm/hat lamexempl fromthe Contractorsice
Lnse Lwforthe
002-9 following reason.(Section 7071.5,Business and Profeulons Code:Any dty°r TI MP MECEROR POLE INST. "
red countywhkhrequlmsaperrnittowmtmdalleplmpmve,demollsA,ormpalr _
4 anyetmd mpdortoitaissuawe,aleorequlreatheepplimntforsuchpermitto POWER DEVICES
P O ilk a signed statement that he is licensed pursuant to the provisions of the
Fos Centradorb License Law(Chapter with S
ng wecti7000f Di
Section )of VALUATION
Ci t9( SWIMMING POOL ELECTRIC
��5 de l of basis for
Business and Campden.Any)vioIhM lation f exempt therefrom and
O Y the basis for the alleged exemption. Any violation perultbn.cat m re any. OUTLETSSWITCHESFIX TURES
five hundtor spermit$SM. theappBcant toadull pevltydn°t more 1Fun
flue 1,a,ownerdelof the pr.
/,as owner of the ro NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑ p perry,ormy employees tarot
aswithwageatheredole -
compensation,Busi.cthew°rrefess .Cdum Wn o.fiecim'o License La.O d for
use(Sec.apply
to a noss and f property
Code:The lds crimp improves
s License Law
5$ does not apply torn owner asp rough who bulorimproowidedreoM and hat each OCC.GROUP RES.UNITS
who oveewch work himself or ed or°ugh hiown .If,hoemployees,provided building
or
improvementsarenmintendrayear foamered oletior the however he deer ill have TOTAL:
improvement W sold within oneyearofcompletbn,the owner-bullderwill have
the burden of proving that he did not build or improve for purpose ofeale.). QTY. PLUMBING PERMIT FEE
u properly, FLOOD TONE APN
L as owner of the am exclusively contracting with licensed PERMR156UANCE'
enntadoa to construct the projed(Sec 7016,Bualncu arta Pro(eashm,Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN As VENT-WATER(RA)
Wilde or'Impmm,thereon, and who contracts for such p7ojede with a - FEE SUMMARY -
or(a)Ilmnsed pursuant to the Contractor.License Law.- BACK FLOW PROTECT.DEVICE
am exempt under Sec. B At P C for this mownOUTSIDE FITS
`,•moi— j ., DRAINS FLOOR ROOF,AREA,COND. 'SANITARY REC�p
ne
Data
—
WORKMAN COMPENSATION DECLARA ION pp(T(3gps PER TRA LTA% Y N
s If)
hereby a(llrm That 1 have a mrliBcate of consent to sslf-Inure,or a RECEIPT Y
380D Libteo(Worken'Compensatlonlnsunnce oracertlfWd copy tM1ereo!(Eec. CAS EA.SYSTEM-1 INC.YOUTL ARK FEE Y N
Policy
ICJ
Policy
PY GAS EA.SYSTFAS-0VEA 4(FA) RECEIPT Y
Com any •. BUILDING DIVISION FEES
Certified copy W filed will
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'[ECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA 131D
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. DRIC
(This section need not be completed It the permit ta for one hundred dollar P
(S10(ilmless.) WATER FIEA77]t W/VIM/ELECTR O ENERGY FEE Y - N'
I mdlfy that in the perform em of the work forwhich this parentis Issued,
1 shall not employ any person in any manner w as to become subject to the WAIL(SYSTEM/TREATINGWorkers Compenaatlon Lawdol California. Date PAID
CI Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exernptlon,you -
should become subject to the Workers'Compensation provhdom of the Labor - TOTAL:
CC Code,you must forthwith comply with such provisions or this permit shall be ' r "
,� Gdeemed revoked. BUILDING FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaf0rm that them is a romtmctl°n lending agency for the perlorm� ELECTRIC FEE
D Z ante of the work for which this permit W issued(Sec.3097,Cie.CJ TOTAL:
.L) O Lenders Name . - PLUMBING FEE
LL's Iender'.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mnitylhat l have mad this application and statethat lheabovelnf°rmatlon
a Is correct.Iagree to comply with all city and county ordinances and slate laws . PERMIT ISSUANCE FEES PAID:
.} W relating tobuilding constructIce,andhemby authorize representatives of this -
city to enter upon the above,mentioned property for Inspection purposes, ALTIa?ORADDTOMBCH. Daft Recel f#
_ (We)agree to um
ve,Indenity an d keep harmless the the City of Cupertino P
- sgalmtllabilltim,judgments,mrtaandexpenaeewhichmayetanywayaecme AIRHANDLING UNIT cro I oolict M) _ SUBTOTAL:
agar tQjy in consequenm of the granting of this permit.
_gF A ��/ AIR HANDLING UNIT(OVER 10,000CFTO CONSTRUCTION TAX -
S rutummooff Appp_Ecacat^/Coonlrador Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIltheapplicare re rcbullding rRtvpaet store or handle haeardoue HEATING UMT(TO 100,000BTI]) Date Recel t#
materlal as deeded by the Cupertino Municipal Code,Chapter 9.12,and the
Ilnalth and SatdyCIon 25532(.)7. HEATING UNIT(OVER 100,000 BTU)- TOTAL: eC.z
❑Yu
-" Wlllthe applicant r turc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - I UAN�DATE
4 whicheMaougement Ir rontamiwnta ae deflud by the Bay Arca Are ![p["IBLLl��i
Quality Management Dist BOILER-OUMP(3FR'DR l00,IXq BTU)
reYn o
issue tact thehvz °usmaterialsrequimmenlaunderChapler6.95of BOILER-COMP(OVER 100,000 BTU) 1 1990
I he CalifomW Health SofetyCWe,SMions25505,25533and2S536. I dGR •S
understand that if the building does not currently have a tenant,that It W my NEW RESIDENTIAL MECO. SQ.FT. -
-_ responsibility to notify the occupant of the requirements which must be met
•
priLtp44uanmofaCcalficateof0empancy. - city Of N—a�{IQ(ft..11{� ,
neo°r authorlud agent Liate - - ISSUED BY:
TOTAL:
i
'OFFICE COPY