21513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PLRMITNO.
B°ilding Address: 21513
413X
nevap 'none: - A A A
WJLU CITY OF CUPERTINO-BUILDING DIVISION q
/`Lie.No: APPLICATION / PERMIT --L
l�
00 O /I x� v /rJ /�C W BUILDINGS-ECIRICALPLUMBINGMECHANICAL CATEGORY CONTROLN
Architert/Engine /�, o;
/ QTY ELECTRICPERMIT PEG BUILDING PERMITINFO
Address �D //�(�/f� L+ p �G[.[, PERhfiT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commene APPLIANCESRIESIDENfIAL JOB DESCRR'I'[ON
Ingwlth Semon7000)of Divlslon3 olthe Busineasand Pro(eekonsCode,and m
time.is in
LlcntrClass Bf/J j.and effect /5-i/ PANELS �a ���
Date /57 T V
ARCHITECT DECLARATION 701-100 AMPS
070 I understand my playshall be used as public records OVERIO30AMPS SQ.Fr.FLOOR AREA E/SQ.Fr.
FU E Licensed Pro(evb.l SIGNSELECTRICAL
c. OWNER-BUILDER DECLARATION SPECIALCTRCUIT/
71., Zg Ihcmbyatftrm that Iare exempt from the Contractor's License law fourth. ,iPOLE INST.
OR— following reason.(Section 70115,Business and Professions Code:My city or TEMP METER OR
P� ounty which requirea a permit to construct,alter,Improve,demolish,or repair
any strumme prior to fro issuance,also requires the applicant for such permit to tV`ER DEVIC
cES �' /J
K V [Ilea signed statement that he Is licensed pursuant to the provlslons of the '-
3 O t� Contradori Licerse Iaw(Chapter 9(commencing with Section 7000)of Divi- I A —
SWIMMING POOL ELECTRIC
sion3ofthe Buslnessand Professions Code)orthathelsemmpttherefromand _ VALUATION
the basis for the alleged exemption. Any violation of Section 70315 an
«�]
applicant fora mit subjects the applicant to a civil ml namarreethan �\O�TII.ETSSWITCHF_SSXMtES L d0 a Qs✓
� C`c lNe lir la PP pt ty V
GWWI tl ¢hundred dollars%$X)). NEW RF9�P113ALELECTR
7 6 1 as owner of the property, 'LS:- SQFT.
❑, p perty,.r my employed with wag as their sole STORIES M'E CON5172UCTION'
compensatlon,wllldothe work andthe structure it Intend¢ orofferedfor lD--" X .M1'
p
sale(Sec.70K Business and Professions Code:The Conerartot Liceruel.1w b^� s
$$ does not apply to an owner of property who build¢or Improv reon,and OCC GROUP RES.UMTS
whodoesauchworkhmaz1forthroughhhownemployed,proaid Watsuch
improvements am not intended orof(ered forsale.IL however,the dingor C I TOTAL:
improvement sa ldwithinoneyearofcomplmiontheowner-bind' illhave
t rden of proving that he did not build or improve for urpose of sale) QTY. PLUMBIA GPEAMIT FEE FLOODPDNE APN
Ln L p
a. net of the property,am exclusively contracting with licensed PERMIT ISSUANCE,'
contract on to construct the project(Sec.7044,Bess umnand Professions Cade;Code;
The Contractor's License law does nor apply to an owner of property who ALTER-DRAIN ,VENT WATER(EA)
build, or Improves thereon, and who contracts for such pi jects with a
c'$B_t[anor(s)licensed pursuant to the Contractor's License Law. gA« V✓PROTEC7 DFEE SUMMARY
1 I_I I am exempt under See. B&P C for this mason EVICE QUIESID. ..
1 Owner D N A ROOF,AREA,MND, SANrrARY Y_ N_
Date RECEPT p
ORKMAN COMPENSATION DECLARATION FLCt61TRF4 PER TRAP SCHOOL TAX Y N_
❑1 here affirm that I have a certificate of consent to ul(-Insure,ora iT —
cenificateofWorkerCompensatlonlnsur ceoracertiflM copy thereo!(Sec. RECEIPT
`- 3800,Iab COC GAS EA.SYSTEM-I INC.d OUILEIS PARK FEE Y N
Policy N 12—,012 5 � J Q ftECEB'I M
.=any GAS EA.SYSTEM-OVER 4(EA) BNL RECEPTVISIO\FEES
❑Certlfled ropy' hereby furnished.city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�j Cetli!°d ropy Is filed with the city Inspection division.
J� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE IRM PAID
COMPENSATION INSURANCE
(Thssecti.neced not becompleted lithe permit laforonehundred dollam SEWER-SANITARY-STORM EA.MET, Date Recei til
(St 00)orless3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the person nceoftheworkmanner fx ax to hthis penultis Ito it; —
1 shall na employ any person In any manner ro as to become subject to the WATER SYSIFM/TREATING
Workers'Compensation laws of CalKornla.Date
Z PAID
Z Applicant
Z O NOTICE TO APPLICANT:If,aker making this Certl(Icete of Exemption,you NSV RFSIDENf1Al PLMB.__SQFI'. Date Recei [N
should become sub eet to the Worker Comperoatlon provislora of the Labor
~ N Code,you most forthwith comply with such provLsl.ns orthis permit shall beTOTAL:
LU > domed revoked. B ILDING FEE a.
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE a
I hereby afflrmthat there is a construction lending agency for the perform
7 Z ance ofthe work for which this permit is issued(Ser.3097,Civ.C.) TOTALELECTRIC FEG:
U O Lender's Name PLUMBING FEE
LLL) Lendely Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certlfythat l have read this epplicatlonand matethattheabove Information4 beenoc.Iagree to comply with all city and county ordinances and mate laws PERMITIRRIANCE FEES PAID:
�. N relating tobullding construction,and hembyauthorlu representaRvd.fthis
F Z cRytoemerupon the abovcmentioned property for inspection purposes. ALMRORADDIOMECH.
(We)agree to save,Indemnify an d keep harmless the City of CuperHn. Date Receipt#
agausthebittles,jadgments,comsand expenseswhim mayln anywayamue AIR HANDLING UNIT(to I0,000CFM)
against said City in consequenceof the granting of this permit. SUBTOTAL,
AIR HANDLING UNTr(OVER IO,000CFM) CONSTRUCTION TAX
Signature
HAlZA o(ApplRDOUS MATERIALS DISCLOSURE ontractor Dale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA
Will the applicant or future building occupant store or handle hazardous HEATING UNIT 00 100,000 BTU)
nuterialas defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recel Hf
I❑Mand Safety Cafe,ScNoion 755324)1 HEATING MIT(OVER 10,000 BTU) TOTAL: w
Will the a ❑pplicant orfuture building occupant useequipment ordevims VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazard...air contaminants as defined by the Bay Area A4
v
Quality Management District? BOILER-COMP(311P OR 100,DM BTU) P(a- O
4 Yes 1�No U
y have read the haea na materials requirements under Chapter 6.95 of BOILER-COMP(OV)R 100,000 BTU)
/ the California Health&Safety Cale,Sections 25505,25533 and 15534.1
understand that if the building does not currently havep tenant,that it is my NEW RESIDENTIAL MF.CH. $0.77.
ngeo�itytonaily the.ccupant of them Ire n/s which must be met
pd.r W)amiancc of a.Certillate°fOcmpa _
/ r
Owners authorized agent : Date
z TOTAL: ISSUED BY.
OFFICE COPY