21589APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
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Building Address:.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICA PLUMBING-MECH LAICAL
r
Cmum m'.Nam¢: Lie. No:
l Q J
CATTGDRY
CONTROL #
Architect/Engineer. Lk. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address '-
BLDG hl,�l
- PERMITISSUANCE D_ cu
LICENSEUCON CTO SD CLARAT N
IMrebyaffirmtMtlamleme Bund pr Wonsof Chapter9(commene-
APPLIANCFSRESIDENTIAL
] DESCRR'1'ION
PANELS
ingwith Seelon70W)of DlvhWon3 ofthellu inessand Professions Code, and my
license is In full farce and cffed.
Liconse Claes --+ Lic.X �L 3D N' /
.
DateContractor
ARCHITECT`S DECLARATION
I understa d my plans shall he used as public records.
Licensed Professional
2(1-1000 AMPS
OVER 1000M
SQ. Ft. FLOOR AREA
B/SQ. FL
'
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TTfp, METER OR POLE INST.
following reason.(Section 7031.5, Business and Professions Code: Any city or
=ntywhichrequimapemdttomm"ct,alwe Improve,dem llsh,orrepalr
anystm=mpdortoirole amalsorequimatheappllantforsuchperinitm
file a signed statement that he le licensed pursuant to the provisions of the
]OWER DEVICES
_
SWRdMING POOL ELECTRIC
q OUMETSSWITCHESFIXTURES AP 13rei
Contractor's License Law t0upter9(commencing with Section 7000) of Divi-
elan 3 of the Business and Professions Code) or that he le exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031S by any
VALUATION
Pat
applicant fora permit subjectathe applicant to a civil penalty of not more than
V
'
five hundred dollars ($500).
❑ I, act owner of the property, or h employees with wages r there sok
C. BusBothe work andthealmcture V not intended or offered for
sale (Sec: Business and Code: The Contractors thereon Law
NEW RESIDENTIAL ELECTR
ES
TYPECONSTRUCTION
TOTAL: (�
apply f property and
does not apply torn unser of p rough who Wilds or yeas, provided that
whodceseuch workhlm.e8orthrough hisownemployeee, providedthatmch
Improvements are not intended oroffered forage. If, howeveythe Wilding or
improvementlesoldwithln oneyearofcomplctton,the owner-bullderwlll have
tl udeno(pmving that he did not build or improve for purpose of sale.).
L,J E as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7064, Business and Professions Code:
OCC. GROUP
RFS. AMTS
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
PERMIT ISSUANCE
The Contracture License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pVJects with a
c0,[Lt.ad.(.) licensed pursuant to the Contractor's License Law.
L� I am exempt under Sec. B & P C for this; reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECER'f N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-Inarre, or a
FIXTURES. PER TRAP
SCHOOLTAX Y_ N_
RECEIVE N
GAS F.A. SYST3,44 INCA OUTLETS
PARK FEE Y_ N
RECTIPT
certificate ofWorkeri Comperuathonlesumcce or a certified cepythereof(Sec.
3800,1abQ
GAS EA. SYSTEM-OVER4 MA)
BUILDING DIVISION FEES
CoPolicy ma
arnfiedon le amby
❑Certified copy Is filed With the a tropectkm division.
GREASE/INDUST'AL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SANTFAAY-MRM EA 200FC
COMPENSATION INSURANCE
(this section need not be completed If the permit E, for one hundred dollars
(5100) or leas.)
I errtify that In the performance of thework forwhlch this pemUt I. leaned,
I shall not employ any person In any manner w as to become subject to the
Compensation Laws of California. Date
ApplicantNEW
Date Recel t#
`
WATER[ -CATER W/vEN.I./ELDCTR -
ENERGY FEE Y_ N_
PAID
Date Recel t#
WATER SYSTEM/TREATINGWorkers
RESIDENTIAL PLMBSQFt.
.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
a
should become subject to the Workers' Compensation provisions of the Labor
TOTAL:
BUILDING
Cade, you must forthwith comply With such provisions or this permit shall W
SEISMIC FEE
deemed revoked.
CONSTRUCTION LENDING AGENCY
T hereby affirm that there is a construction lending agency for the perform-
ante of the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender'. Name
Lenders Address
TOTAL:
ELECTRIC FEE
PLUMBING FEE "
QMECHANICAL PERMIT FEE
MECHANICAL FEE
Imrtlfythatl havemadthls application and statethattheabovelnforroatlon
iscerree. l agree to comply with all city and county ordinances and state laws
relating tobuilding construction, and hereby authorize representatives of this
city to enter upon the aboverrentioned property for impaction purposes.
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date Receipt#
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
gmems, et. and expenses which may In any way accrue
against liabilities, ydw
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING 11MT (OVER 10,000 CFM)
CONSTRUCTION TAX
.gah aid try con ueree of the granting of this permit
.�.i
EXHAUST HOOD(W/DUCE
CONSTRUCTION TAX PAID:
Ensnare of Applicant/Contrytor Date
HAZARDOUS MATERIALS DISCLOSURE
Will lheappliant or future building occupant store or handle hazardous
mzterWl as defined bythe Cupertino Municipal Code, Chapter 9.12, and the
ITealth and Safety Code Section 25532(a)7
❑ Yes No
r]
- Wiye. applicant or future bonding occupant use equipment or devices
which emit hazardous air contaminants a defined by the Bay Area Air
Qiality Management Dlstrict7
Ya rl No
(have read the hazy one materials requirements under Chapter 6.95 of
HE UM7(TO 100,000 BTU)
Date Recei t#
HEATING UMT(OVFR 100,000 BTN
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
A
PID
i{
1fj
BOILER -COMP DEEP OR 100,0(10 BTU)
-
BOB, ER-GDMP(OVER 100,000 JIM)
the California Health & Safety Code, Sections 25505, 25533 and 25534.[
understand that if the building does not currently have a tenant, that it is my
�l • u, Vl
NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occopint of the requiremen .which ustbemet
prior to issuance ofaCerti(late o(Ouvpanry.
IstW
"��..�
Nsy, at woo"
TOTAL. ]ISSUEDHY:
Owner or authorized agent Date
OFFICE COPY