21543 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—..USE BALL POINT PEN ONLY
Huildiali Protect Identification PERMITNO.
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dime 21543
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(.J • CITY OF CUPERTINO-BUILDING DSION
c '°n. Name: ' . APPLICATION'/ PERMIT
BIIILDINGEECTMCAI.PLUMBINGMECEANICAL CATEGORY CONTROL
ect/Engineer: Lk.No:
- ' ` ''ELECT � l -d"� ,' BUILDINGTERMIT INFO
QTY `• ELECTRIC PERMIT.'> ' FCC
Adtlrns: '' - PERMITISSUANCE ❑ .. ,❑
LICF,NSED CONTRACTOR'S DECLARATION
El
I hereby affboothat l am licensed under provisions of Chapter 9(commen APPLIANCPSRESIDENTIAL - ✓'' C:L
Ingwlth5etttona000)ofUlviekn3oftR'Businnaand ProlcxloneCode,andmylicense Is In lWitfgantl effect± / PANELS
LicenseClaq+U U/ Lk.tr ct (�
Date '"11/I Contractor UP TO 200 A MPS
�! ARCHITECTS DE ATION201-1000 AMPS
pQ+ O I understand my plzru iduB be used n public records. OVER IOW AMPS SQ.FT.FL EA S/SS3,FI',
E o(Gj Licensed Professional STGNSELECTRICAL 0
GGGG w OWNER-BUILDER DECLARATION
F]� Iherebyaf@mthatI amexempt frdmthe Contractor'sLimnse Law forthe SPECALCIRCUIT/MISC
p"u1p following reason.(Section 70335,Buairm and Pmf nniom Code:Ancityor
countywhich requires a permit to construct,alter,Improve,demolish,ormair TEMI'.ME[TR OR!'O -INST. ,
'1� s anystmeure pdorto its issuance,also requirestheapplimnt for such permitto
K file a signed statement that he Is Ilcome i pursuant to the provisions of the VRDF�Al,
Contrsam'.License Law(Chapter 9(commencing with Stolon 70110)°(Divi. ECfRIC
slon3 of the Buttress and Profeselmu Code)or that he is exempt therefrom and VALUATION
•-t the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the a pplicant to a civil pent try of not more t hon FIXTURES
five hundred dollam($W,- LECTR'❑I,ateownerofthe property,or myemployers with wagn as their Bole —`'Qd'T /STC TYPE CONSIRUCT70N
compensation,wRldo the work and thestmeture is not Intended or offered for
,d Fp sale(Sec.7614,Business and Profession Code:The Contractor's Licence law
does not apply to an owner of property who Wilds orimproves thereon,and •a
G whodoessuchworkhim lforthr°ughhisownemployees,prov(ded thatsuch OCC.GROIII' RES.IINITS
Improvements are not Intended oroffered for sale.If howervepthebulldingor TOTAL: -
improvement Issoldwithln oneyearofcompinlon,theowner-W Bderwill have
'
tl_lIurden of proving that he did not WRd or Improve for purpose of sale.). QTY, 1` 'PLUIv16ING PERMIT' " 16 FEE'
IJ L as owner of the property,am exclusively contracting with licensed FLOOD ZDNE APN
contractors to construct the rot PD2MITISSUANCE
'Mep doe(Sec,appy to an o ane loo omelet Code:
Wil Contrenor's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds m Improvn thereon, and who contracts for such proem with a ,FEE SUMMARY
cgp(panor(sexempt under ant Sm
the Contractors License Law. BACK FLOW PROTECT.DEVICE
LLII I am exempt under Sec B&P C for this reason
SANITARY Y N
Owner Date DRAINS ET-L3DR ROOF,AREA,CO RECEBT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP - SCHOOLTAX Y_ N_
❑I hereby affirm that I have a rertificate of consent to self muum,ora RECI]IR N
ormflmteofW°rkerf C-roP-malts-1..un)nmonQmrdfieed copythennf(Sec. GAS FA gYSITbltINCA EpS
3800,[abC�lil'"G�1 �/ l� PARK IEE Y N
I'ollry a
RECEIPT a
Cnmany-C' GAS EA.SYSCEMA 4(EA) BUILDING DI VISION I'I:IS
.Cerilfie co 6 hedwith t le citysed. (EW
WASMINmiCEPTOR PLANCHECKFEE
�rtlfled copy V flied with the city Inspection dlWelon. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(This section need not W completed if the permit b for ors hand red dollars SEWER- ARY-STORM EA.2WFT. DatC' Recei 1#
($100)or leas.) INA .I.ERWryEN.I./ELCCTR - ENERGY FEE Y N
I certify that In the performance of the work for which this permit la Issued, —
I shall not employ any person In any manner so as to become subject to the W SYSTEM/TREATING Workers'C°mperuation laws of Califomis. Date PAID
O Z Applicant
RESIDENTIAL PLMB. SQ,F7. Date Recei t#
Z O NOUCEcome ubICt to the
ager making enationkrovis Em°fempact Labo -
H Ccdu o mus subject mthe Work en'Compensation provblons°(rise Lab be TOTAL:
WW C,dmedmmom forthwith comply with each proNslore orth6 permit shall be BUILDING
> deemed revoked. ..
d O -CONSTRUCTION LENDING AGENCY SEISMIC FEE -
Iherebyalflrmthat there lsamnawttlon lendingagenry for the perform- TOTAL: ELECTRIC FEE
7 Q an,..ftheworkf6rwhichthispermit Ltiasued(&c.3097,Clv.C.) `
(, Inderb Name PLUMBING FEE
14, Lender's naareetQTY. MECHANICALPERM[T „” ",FEE MECHANICALFEE
O I(U lcftifythatlhavemadthisappliwtlonandwatothattheaboveinfor tion
IL is correctI agree to comply with all city and county ordinances and state laws PERMIT ISSIANCR FEES PAID:
W
relating to building construction,and hereby authorlae representatives ofthis
1— Z city to enter upon the above.mentioned property for inspection purposes. ALTER OR ADDTO MECH. DatC RCcei [#
(We)a e to save,Indemnity an d knp harMen the CI of Cupertino P
against Ila dtics,}rdgments,mRsand export
whlchmayln n ay accrue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
against d It n nmquenceof the granting of this ,`/�' '
�v/ AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTIONTAX .
Slgrutu A phcant/ ontract°r EX AU5THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant or future building occupant st6rom handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCcei I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
IicalthandSafetyCedrSection25532(a)? HEATING UNIT(OVER 100,000 BTLB TOTAL: _
❑ Yes raL-,I No ., -
Will the applicantorfuturebuBdingoceupantuxequlpmentordevlces VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
which emit haeardous air contaminants ate defined by the Bay Area Air
Qua lily Management District? BOILER-COMP OHP OR 100,0100 BTU)
Y �1Aa alets
4 es F
have madthehaxar us materialsmqulremarhs under Chapter 6.95 of ROfLER-COMP 100,000 BTU)
the Califc mia Iicalth&Safety Code,Sen ions 25505,25533 and 25535. 1 FL'p ) 1a �n�,�
undents nd that if the Wilding does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT /i fl i ✓ `,
rnponsibility to n°ti(y the occupant of the requirements which must be met
Prior to Issuance oft Certi(Icateof Occupancy. CN/N•/�=
Owner or aulhoriredagcm Date (�
TOTAL:
OFFICE COPY