21284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'ed Identification PERMITNO.
Building Addma:
62 . 21284
2
ere one;
Iii p/ 2F SbZ CITY OF CUPERTINO-BUILDINGDIVISION /O'l��a
cmrt.d°2 /,. u,N°: APPLICATION If PERMIT t
U
Arehltad/Engl er. Lk. BUBAINGELECTRICALPLUMBING-MECHAMCAL CARRY CONTROL If
No'
-- P— QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address � � J pERMITISSUANCEIgS � ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmm APPLIANCESREBDENIAL JOB DESCRE'77IN
Ingwlth Setion7000)ofDlWslon3ofthe Buslneessand Profes.Ionaccain and
licroxabin fuIj deffect. 9�s^�� . PANELS �,,L}-��, `�+y
DateLicoh C. Lk tl4�j><.-�r-(f✓�L- -F/l NJ.' Gil{ -U.1 G
Date Contrado,
ARCHITECIPSDECLARATION 201-1000 AMPS
reOZ I understand my plana shall be used as public record& OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
cO
Z E Licensed Professional SIGNSELECTRICAL
�tN OWNER-BUILDER DECLARATION SPFiCIALCDtCUIT/MLSC
.t.., � IherebyafRrmthstI am exempt fromthe Contractor's Lienee Law for the
following reason.6ection 7MI.5,Business and Professions Cole-W ct or -
p 6 countywhichrequlresapernetoconstruct,alter,Improve,dem.l}ah drrepalr TEMP.MEfERORPOLEINSP.
y� v anystmture priortoits Issuance,also tequirestheappBo( nt forsu rmlIto pQWER DEVICES
E5 O file a signed statement that he Is licensed pursuant to 1�provlsi6rlY of the
Contractors Llcrumlaw(Chapter9(commencing with$e61gn 700())of Div(- VALUATION
�0� Won3oftheBuelneaa and Profmlons Code)orthslheLgev`empt lhc.fm..edSW1MMINGPOOLEL
` ECTRIC
the Weis for the alleged exemption. Any;vlplaTioa of Section 70315 by an r' 1'1 c
o Y OUTLET&SWI7'CHFSFIXIURES QQ
&,,Dani fora pertNt sub' Iheappac9nl Ilii dWl,(wily of ndf i/rorciAan
five hundredd lottars(55001 � I W /wages th 1 NEW RESIDENTIAL E.ECTR_SQ.FT. STORIM TYPE CONSTRUCTION
❑I,
.,=lot
s owwr of the pro or my employees with .tMlr sale
compenefon,wBldotM wor ndthestructurels notirifendedor of1f ,
dfor
O aale(Sec70kiki.lnic essiow Code:The Contractors Lice13iv'
111
don not apply to an owner of property who Wilds orimproveslhemaUnd' OCC.CROUP RES.UNITS
whodaesauchw.rkhlmsel(orthr.ughhi'owriemptoye ,providedtsuch
lnprovements arc not Intended orpffemd.forsile.IQh er,l e gor TOTAL
Improvementiaeoldwithlnoneyeirofnompletion,the er have
t Men of proving that he did'not Wild ar hrP�va f p e e.). QTY, PLUMBING PERMIT FEE
Lj 1,as owner of the property,am excluslvm {ant In�with Ilrensed FLOOD ZONE APN
contract..to construct the project(Sec.7094,Bu a Pro(ealonsCode: PERMIT ISSUANCE
The ContnttoeB License Law does nut apply to an o r of property who ALTER-DRAIN kVENT-WATER(FA) '
Wilds or Improves thereon,and who contracts s ch p(ojecb with• FEE SUMMARY
contractor(a)Danced pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec- B k P C for this reason
DRAINS FLOOR ROOF,ARG,OOND. SANITARY Y N_
Owner Date RECEEPT R
WORKMANCOMPLNSATION DECLARATIONm FO(7l1RES PER TRAP SCHOOL FAX Y_ N_
hereby affirthat I have a ceMRcate of consent to self-Inure,or• RFFLEE'T 8
¢nlficate of Workers'C°mpereatlonlrearance or a certlfied copy thereof(Sec. GAS EA.SYSTEM-1 INC.40I1TLE75 PARK FEE Y N
3800.Lab C.) RECEIPT a
PolicyM GAS EA.SYSTEM-OVER 4(EA)
Com ray BUILDING DIVISION FEES
�Ce copy b hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
.Died copy Is filed with the tty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMG 2Wh7Date Recei t#
(Thlsaetl.n need not be completed tithe permit Is forone hundred dollars
(5100)°rleasj WATERHEATER W/VENT/ELECTR ENERGY FEE Y N
l artifythat in the performance°f the work forwhich this pemdt is issued,
I shall not employ any person In any runner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compencxlon Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICETO APPLICANT.U,after making thin Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
V) Code,you swat forthwith comply with such provlalons orchis permit shall be BUILDINGTEEl
W > deemed rewked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirm that then Is a construction lending agency for the perform TOTAL, ELECTRIC FEE
M Z ..m.fthe w.rkforwhich this permit is isued(Sec.3097,CN.C.)
U O Lander:Name PLUMBING FEE
LL H Lendrea Address CITY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irertifythatl have readthis application and state thattheaboveinformstlon
1 iscomd.I dgreetocomplywlth all ttyand county.rdlnancesand statelaws PERMIT ISSUANCE FEES PAID:
>. N relating tobullding construction,and herebyauthortze representativeso(this
ttytoenteruponthe above-menllnwd properly for inspection purposes. ALTER OR ADD TO MECH.
? (We)a to save,mZronify an d keep harmless the City of Cupertino Date Recei t#
V agaWtllab' les,Pdgments, sandvpenseawhichmayinanywaya.c c AIR HANDLING UNIT TT010,000 CFM) SUBTOTAL:
against City in coneryu rating. t .permit
AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
gruture.f AppDce,t/ ontra br 11121
t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBant or Tutu building occupant store or hand to hazardous HEATING UNIT ITO 100,000 BTU) Date Recei t#
manrlelaedefinedbythe peMno Municipal Code,Chapter9.l2,andthe
Health o
and Safety Code FFI Mon 25533(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: c
111 the applicant orfuWre building occupant use equipment or devices VENTILATION FAN L5INGLE MID) ISSUAI
which emit hazardous alrco taminan.as defined by the Bay Area Air d��IIS
slily Mawgenunt Dl7 BOILER-COMPpM'OR 100,0(D BTU) `
11 N. 1991
ve read the baza sue maletals requlrertrnts under Chapter 6.95 of BORER-COMP(OVER 1W,000 BTU) C 1 } 2
the Gllfomia alth&Safety Code,Sedlons25WS,25533and25534.1
undentandt aUfthe Wilding does not corrently have a tense,that it is my NEW RESIDENTIAL MECH. SQFT. ds�
res powibll- to ndifythe raI flhe requirements which mu at be met Vs r1IE1yYF1
Friar to ance of a Ce I f e my, MI
naror eithoroed agent - Date TOTAL: ISSUEDRY: Wrs9�s t,wt•w.a'K�
OFFICE COPY