21826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERWTN'O.
Ouilding Addresa: v 21826
-)-10 S
wner a acts: one: APPLICATION S AL DA11i -
CITY OF CUPERTINO-BUILDING DIVISION
CnnQt et N/� L t / ULIc.N°: APPLICATION / PERMIT
// ICLCI ff'w jv'n y BUfLDINGELECTRICALPLUMBING. FL MCAL CATEGORY CONTROL
Amhitect/Engineer. LIC.No:
QTY ' ELECTRIC PERMIT,. _, FEE , BUILDING PERMIT INFO.-,f,!:.(:.
Addm,r�/�w,bnT C� 97Fs�( I'ELWT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions Of Chapter9(commenc APPQANCESRESIDENT(IAL JOB 01S 1<1I1ITON
ingwith Se ..7000)ol Divbion3otthe Businemand P.feni.n.Code,andmy
license 1s in full forte and effect. PANELS �-I .. ip .
License Chm LIC �Q
X
DateCoird.mr
ARCHITECTS DECLARATION 201-1000 AMPS
4 ac Z I understand my part shall W used as public records. OVER IOO(i I �lFT. EA � $/`SQ FT
x.d5 Limned Pmfessionsl SIGNSELECTRICAL 9.4s.
C
<?w OWNER-BUILDER DECLARATION SPECIAL CRRCUIT/MISC RR. •••TR
E
GI herebyafBrm that I.emeOpt from the C.rommea License Law for the
o'^ following mason.(Section 70315,Business and Profession,C°de:Any city or M=OR POLE INST.
Countywhich requla permit tomtt
tru ,alter,Improve,demaLL,h,orrepair P. /
anystmmrepriortoiO6=ame,aLwrequlmstheappBcantforwchpermitto POWER DEVICES
file a M13ned statement that he O licensed pursuant to the provisions of the
'O_ Contractor.LEm. aw(Chaptsr9(mmmancingwuh Settlon7D00)of Dlvi- SWIMMING POOL ELECTRIC VALUATION
sin°3ofthe Bu,i .e dPr =f mCode)orthathebeumptthemfmmand
Sn S the basis for the alleged exemption. Any vlolatlm of Section 70315 by any OVILE7SSWITCHF_SFENTURES
� < applicintfora permit subjectsthe applicant to a civil penalty,of not more than
five hundred dollars($SM. NEW RESIDENTIAL ELECTR SQ7r. STORIES TYPE CONSTRUCTION
Y ❑I,as owner of the property,or my employees with wage,as their.ole
s.ZS° mmpenw0on,wllldothe work andmesmmre Ones Wended or offered for
`C p sale(Sce.7044,Bushes and Pmf.loro Code:The Cimmmmrs Lt..Law
i$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES UNITS
who doessuchwork Mmselforthrough hisownemployees,purvided thatsuch
improvements are nm Intended oroffered formic.If,however,thebulldingor TOTAL:
impmvementOs idwthinoneyearofeompleWn theowner-buMerw0lhave .
th moden of proving that he did not Wild or Improve for purpose of silo.). QTY. PLUMBING PERMIT t '.'..FEE FlDDDZONE APN
Lj L a.Owner of the property,am exclusively contracting wim acensed1 PERMIT ISSUANCE
contractors to constma the project(Sec 700,Business and Prafessloru Code:
The Contem or',Lt...Law don not apply to an owner of property who ALTER-DRAIN Is VENT-WATER(EA) ._
Wilds or improves thereon,and who contact for Much pNJem with a ,'FEE•SUMM'ARYh
ydByTaattor0)licensed pursuant to the Ccutvcter.Llan.Law. BACK FLOW PROTECT.DEVICE 'OUTS '�T,f^�?.•(n-
cLJI am exempt under Sec B k P C for this main
D NS RR F,AREA,CONID. (�CV SANITARY Y N_
Owner Date RECEBa1'X
WOR COMPU,ISATION DECLARATION p�.RVRFS,PER TRAP SCHOOL TAX If N_
❑I he
affirm that I have a mrtlffate of consent to self-insum,Or a RECEIPT N
certificate ofWorlvm'Compensation Insurance or a mmltled copy thereof(Sec. GAS EA SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.) RECEIPT N
Policy X GAS.EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com ny
(CertNed copy O hereby fumbhed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy In filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA.200FT. Date Recei I#
(This section need not be completed if the permit O for one hu odred dollar
(S700)or lessEN
) WATER HEATER W/VT/E.FCTR ENERGY FEE Y_ N_
I ramify that to the performance of the work furwhich this permit Is leaved,
I 0ha0 not employ any perwn In any manner w as to become subject to the WATER SISTER/TREATING PAID
Workem Compemetion Lawsof CaIJ°mh. Date
.� Z ApplicantNEWRFSIDENTIALPLMB. SQ_FT. Date Recei t#
O NOTICE TO APPLICANT.If,after making this CerWleste°f Exemption,you TOTAL'
should become subject to the Workers'Compernatlon peavOlom of the Labor
N Code,you mostfonhwith comply withauch provision or<hO permit shill be BUILDING
deemed rooked.
it, CONSTRUCTION LENDING AGCY
SEISMIC FEE
d Ihereby affirm that there b a comhuction lending agency for the perfoms- TOTAL: ELECTRIC FEE
M Z arm of the work for which this permit b Wood 5m.3097,Civ.C.) PLUMBING FEE
02 leoder'aName QTY. -MECHANICAL-PERMIT-," FEE r
IL f Lender'.Addmn MECHANICAL FEE
0 w Imdifythat l have read thbappliati....d statem
thAtheabove lofoution FEES PAID:
O comer.Iagree to comply with all city a od county ordinance and state laws PERMIT ISSUANCE
y a relating to building construction,and hemby authimee representatives of this
U) cit to enterupon the above-mentioned for W ion se,. ALTERORADDTOMECH.
? city
agresave,Indemnify an d property
rrolm the City of Cu pemmo Date Reecipt#
l.J against liabilities,' Of.A oil e.penses which may In anyway acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agAns i o n.quenec°fthegrantingotmbpemnit. CONSTRUCTION TAX
�l AIR HANDLING UNIT(OVER l0,000CFM)
'Signature of Appliant/Contractor I Dattee allAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT 100,000 BTU)
Will the applicant or future building opant store°,handle hazardous Date Recci t#
rtaHealth and Safety Code Section 25532(a)? TOTAL:
ttr[A.,defined by the Cupertino Municipal Code,Chapter 91Z and the HEATING UNIT(OVER 100,0(0 BTU)
GS'�,�
❑Yell MNO VENTILATION FAN(SINGLE RESID) ISoLM DATE
Will the appllaest or lutum building occupant use equipment ordevices
which emit hazardou,air contaminant,as definod by the Bay Area Air BOILER-COMP DIP OR 100,0(3 BTU)
Quality Mamgco cet District? ���. 11991
❑ Ye
(have read me Nazar nNowO
us rteriarequlmments under Chapter 6.95 of BOILER-COMP(OVER 1fA,0000N)
the California Health k Safety Code,Sectiom75505,75533and 25534.1 N�yyRlSIDENITIALMCCIi. ;QIT
understand that if the building does not currently have a tenant,that it O my . . (.:� n(of CL11M��a
responsibility to notify the Occupant of the requirement,which must be met W Y"'
prom to Rssu;mm a.CemifcAurtfOmpancy. s.--, nttt���p��-•
Owner or authorized agent Date ISSUED BY \vY'V�—�K
TOTAL:
OFFICE COPY