21084 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES= USE-BALL POINT PEN ONLY
Building Protect Identification ' PERMIT NO.
Rue Ing Address:
Ca
, 210 8 4
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S a l7H'GQ T)e 1Q )� �Jp CITY OF CUPERTINO-BUILDING DIVISION O_I N� • A,
� on1a or° ' APPLICATION / PERMIT L- L
� c le 3 BUR.DING-ELECTRICALPLUMBING-MECHANICAL CATEGORYCONTROLp
Arc Itect/Engineer. - LIc.Na
QTY ELECTRICPERMIT FEE " ' BUILDING PERMITINFO
Address: -
PERMITISSUANCE ❑, . 1 ❑•
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwlth Section 7000)ofDivlslon3 dthe B,ui..aadP afeWonsCode,and my '
ilmnss is in full and effect. 3 4/dlY PANELS (� 1 I �s ar•" .
Lken s ss Lk.B I [�- V•,+oT
Date Comracmr '
ARCHITECTS DEC RA 10 201-I000 AMPS
I understand my p6v shag he used as public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA 8/SQ.FT.
!G U Licensed Profeesloo d SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCIIIT/MISC r -
f, I hereby affirm that l am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Pourofessions Code:Any city or
F�cntywbkbrequbre.apermlttommtmu ,altenimpmv de=lish,orrepabr TIME,METER ORPOLE INST. y',
any atmcturep rlInto
mits Issuance,abo imslheapplicentforsuchpermitto pOWER DEVICES
1 RIs a signed stateent that he is licensed pursuant to the provisions of the -
3 w Contractor.LiEe. hapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
SOS kcn3ofth.BuslnessanIf Professions Code)or that he ll exempt therefrom and - ;VALUATION
' the baste for the alleged exemption. Any violation of Section 70715 by any
G'
applicant for permit sub' thea applicant to a civil al ofna more than OUTLETSSW[T'CEIESHXT[7RES aC)d -
pS0 live o lects PP penalty
t`c Fj1,.0red dollars($5011, NEWRFSIDENHALELECTR SQ.FI,
I,ae owner of the property,or my employees with wages as their sole STORIES TYPECONSTRUCTION
compensation,will do the work and the structure isnot intended or offered for
sale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply,te an owner of property who builds or improves therem,and ' I' .00C.GROUP RES.UMTS
who does suchwork hlma df.rthmugh his own employees,provided that such -
Improvementsarenotintendedoro(feted for sale.If,however,the building or - TOTAL,
ImpnwemenHseold within one yearofcompletion,the owner-bu lderwill have ,
t1�a ben of proving that he did not build or improdeforpurposeo(sale.).' QTY PLUMBING PERMIT FEE FLOOD TONE APN
I,J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Cont on?.Llmnse law don not apply to an owner of property,who ALTER-DRAIN Its VENT.WATER(EA)
builds or Improves thereon,and who contracts for such projects-with a
co,0tt.{IFEE SUMMARY
Sm actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE.
L_J I,am exempt under SB k P C for thisreason
_ R, AREA,COND. SANITARY- Y & N
Owner Date - DRAINS FLOG ROOF,"WORKMAN COMPENSATION DECLARATION RICEIa'fN
FD(TURES PER TRAY SCI;OOL TAX Y N '
LYJI hereby affirm that I have a certificate of consent d self-iname,themof ora RECEI'T M
3800,,mteLab of Workers'CompetuaHon Insurance oracertl(kd mpythereo(($m. GAS F.A.SYSTEM-1 INC.4 OUTLETS
Polis Lab CJ ?* PARK FEE RECEIPT Policy p '��i �1 r( - ,
Com any G�j[�ebyfurnished.
- GAS EA.SYS'1'EM'OVER<fFA) BUILDING DIVISION FEES
[]Certified copy's hereby ththe city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
- Certified copy V tiled with the city inspection division.
GREASE TRAP
CERTIFICATEOF IXETFROM WORKERS' PAID
COMPENSATION
IN INSURANCE SEWER SANITARY STORMEA 7 - Date Recei t#
Qhiseectlon need not be completed l(tM permit.for one hundred dollars 00HT. -�
(81 I mctifess.)'. WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I 11 not that In the person in an tmannerh.work an as to
co permit is Ito theed, —
I shall not employ any person In any manner at ss to become subject to the WATER SYSI,FM/
WorompensaHon Lws o(Callfornh. Date TREATING PAID
O Z Applicant
.
Z �. NODGETD APPLICANT.If,after making this Certificate o(Exemptlon,you NEWRESIDENTIALPLMB. SQ,7. Date Receit#
,
Should become subject to the Workers Compensation provlsloru of the Labor - - TOTAL:.
~'y Code,you must forthwith comply with such provbsimu orthb permit shall be
W > deemed revoked. I ING FEE
W
p CONSTRUCTION LENDING AGENCY, - SEISMIC FEE l
I herebyaffirmthat there is a construction lendingagency for the perform- TOTAL: ELECTRIC FEE
M Z ance o(the wuikfor which this permit is issued(See.3097,Civ.C.)
V O (.ender.Name - PLUMBING FEE -
LL I- Lender'.Addresa - - Q1Y. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify that l have read thisapplication an dsmlethattheabovebnf.mvition -
6 Iscorrect.I agrn to complywith all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
N relating to building comtruction,and hereby authorlu representatives of this -
H'Z city to enter upon the above-mentioned property for hupectlon purposes, ALTER OR ADD TO MECH. Date Receipt#
_ (We)agree to save,indemNfy an d keep baroness the City of Cupedloo -
101 abilitles,j,idg fits, sand expense-which may in anywayacaue . AIR HANDLING UNIT(7010,000 CFM) .SUBTOTAL:'
1 In 9O ys (the granting of this perrrdtO
IJ/. .4p I
MR runvuNc uMT(ovFit 10,000 cFhil CONSTRUCTION TAX
Signature of AY)plicant/CorttEactor Date PXHAUSTHOOD(V/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous HEATINGUNIT(TO100,000BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t# '
HmIthand Safety Cade,$etlion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
Q Yea .''.'7Z7�C'1 No - •. �
WBlthe applicant turn,building occupant use equtpmentor devices VFNITLATION FAN(SINGLE REBID) {7pJNCE DATE.
whichermt hazardous,air contaminants as defined by the Bay Area Air
Qu a lily Management Dist 7 -materials reBOILER-OOMP(3HP OR 100,000 BTU) ��� 1930
1 Yee No - sv,
have read the hams aqulrerrmnla under Chapter G95 of BOILER-00 100,000 BTU) I
the California Health& fety Code,Sectbons25505,25533 and 25534.I
understand that lithe building does not currently have atenany that it is my NEWRESIDENTIALMECH. SQ.FT. - Tjpes aatm��Plsw,yJ'fesn .
resp? bbllaytonotbN'liccRoccupancy.
t of the requirements which must be met liI(a C+a�tg;,jfjjj,Ey
rt ua ofa I DG��b }`�` ra '�,• .B,,
ner or author) sent I - Date ISSUEDBY:
TOTAL:
'OFFICE.. COPY