21407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
Building Address:
/owgi M. 21407
/^ners ante: on/e: p - p A A
C . 2J-2- 7 CITY OF CUPERTINO-BUILDING DIVISION �_�l� r ,
c n anar'sName: Lir.No APPLICATION I PERMIT
® 'frU H� ✓ BUILDING-ELECTTUCAI.PLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aa�� S/3PR7iGA�S4j VY✓IKEA .S.J.
PERMIT I55(1ANCE ❑ El ® El
CONTRACTOR'S DECLARATION
I hereby ection 70that 0)of Dt Boomed 3ofthe usiroidPmfessims9(emmcn APPUANCESRESIDENTIAL JOB DESCRIPTION
'ngwe is i n1on to
affeon3o(thc BuelnessandProfesslonsCode,and my
limns is in fo d d(ed. J)AA p PANELS
License C). — LIc.N 2 2W3 .
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
a0 7 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ.FT.
O
ce
C
d U Licensed ProSIGNS ELECTRICAL
Professional SIGNS
�¢c. OWNER-BUILDER DECLARATION SPLCIALCTRCUIT/MLC I l; '' / 1f� '-T' `I*s•7
FE•f'u1 owing rason.(ha/Iam 1.5,Buempt siness and
Contractor's License Law for the rJ
�g county hichre.(ires a pern31.5,Bustractand Professions Code:Any ntyor �pMECERORPOLEINST. � �� �; �� J i�
¢ county mmprqulresapmance aLr requ,alter,impmvgtforsu h,orre airtto
0.' gaG anystmchrepdorto lis issuance also requlrestheappnant for such perultto POWER DEVICES ?�J� p/
y'i F O file a signed statement that M Is licensed pursuant to the provisions of the ' /
Contractors Lkamm Law(Chapter 9(commencing with Section Neff)of Divi-
'105 sion3ofthe Busineaand Professiore Code)orth0heisemmpttherefromand SWIMMING FOOL ELECTRIC VAN
Q5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHE&FIXT URES
applicant for a permit subjects the applicant to a civil penalty of not more than
c,.. five hundred dollars($500). NEW RESIDENTIAL FT TR
SQ.FE STORIES TYPE CONSTRUCTION
7. ❑Lasow,willner oche taperty,nr my employesnotes inendedth wages rtheirsole
7.� compensation,Busirehewarkandthes Code:The Contractors
License
Law
O
.1.&.70K apply
Business and Professions Code:The or improves Llense law
S$ does not apply to an owner d property who builds or improves thereon,and _ OCC.GROUP RES.UNITS '
who doessuch work himself or through his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within oneyrarofcompletion,the dwner-builderwill have
the4uNen of proving that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ppN
u I,as owner of the property,am exclusively mmracim,with licensed pERMITISSUANCE 'M
contractors to construct the project(Sec.7016,Business and Professions Code: W
The Contractor's License Law does not apply to an owner of property who
bunds or Improves thereon, and who contracts for such projects with a ALTER-DRAW k VENT-WATER(EA)
<rnor,O)sensed pursuant to the Contractor's LicenseLaw, FEE SUMMARY
❑I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT
Oa--aM WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP { //y1/�� SCIMOOL TAX V_ N_
s�I hereby affirm that I have a certu a c of consent to se6-Insure,ora v W RECEIPT N
MOO.aleolWorkeri Campenauonlruuranamaarti(kd mpytherrof(Sec. GAS EA.SYSTFM-1 INCAOULETS PARK FEE Y N
3800.Lab CJ RECEIPT N
PWicy N CAS EA.SYSIIM-OVER 6(EA)
Com any BUILDING DIVISION FEES
Certified copy is hereby furnished, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FT. Date RCOCI t#
(fhissenion need not be completed If the permit is forone hundred dollar
($101fimicss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
le difythatintheperfarmanceoftheworkforwMchthispe.itiissu.d,
I shall not employ any person in any manner so as to become subjectto the WATER SYSTEM/TREATING
Workers'Compensation[aws of California.Date PAID
O Z Applicant - NEW RESIDENTIAL PLMB. SQ.FT. Date Recei I#
Z 0 NOTICE TO APPLICANT:][after making this Certificate of Exemption,you
should become subject to the Worker'Compensation provisions of the Labor TOTAL:
CC
(D Code,you must forthwith comply with such promos or this permit shall be BUILDING ELE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d-� IFerebyaffirmthat there is aconstmction lending agency for the perform TOTAL: ELECTRIC FEE
M Z accent heworkmrwhkhthLs permit 6 issued'(Sec.3 ,Ci,.C.) GO .DD
V.O Lender's Name PLUMBING FEE ;
ly F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcenifythatlhavemadthbappUationand statethatthe above information
S correct.I agreetacomplywith ancityand countyordlnancesand statelaws PERMIT ISSUANCE FEES PAID:
>- 0. to building construction,and hereby authorize representatives of this
I— N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to ave,Indemnify an it keep harmless the City of Cupertino Date Receipt#
V aga inst liabilities,pdgmenr,costs and expenses which may In any way amore AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal taaId Ci i uqu nceof the grant ing of this permit.
j AIR HONORING UNIT(OVER tO,WOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Orate IXE1Al15T HOOD(W/DUCT) CONSTRUCTION TAX PND:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or form,building occupant store or handle hazardous HEATINGUMT(T0I(xL0o0BTU) Date RCCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12/and the - -
Health and Safety Cod ct2ion32(a)P ' HEATING UNIT(OVER IM,"BTU) TOTAL:
F1 Yet; _ UNo
Willtheapplicam orfuture building occupant use equipment ordevices VENTILATION PAN[SINGLE RFSID) ISS -ATE
which cult hazvdom air contaulrunts as defined by the Bay Area Air �
Quality Managers- Inst n7 BOILER-COMP PHP OR 100,000 BTU)
No
11vcrcadthehaaTousmateria requirements under Chapter 6.95of BO ER-COMP(OVER100,000B V) '
the California Health k SafetyCode,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEWRESIDFN"ITALMECH. SQ.FT
responsibility to notify the oaupnnt of the requlreirents which most be met
priort�'"'Jonce da tate of mpancy
3 -r-*
Owner or authorized agent Date
TOTAL: ISSUEDBY: .
OFFICE COPY