21481 APPLICANTTO FILL IN INFORMATION-WITHIN RED LINES — USE BALL POINT PEN'.ONLY
Building Project Identification - - PERMITNO.
Building Address: - xis 21-481
L' —
"` ,, C/f AN Cr Phone:
CITY OF CUPERTINO-BUILDING DIVISION a
Contractors amp: - _ L - APPLICATION / PERMIT
BUMDING-ELFLTRICAGPL@dBINC-MECHAMCAL CATEGORY; _ CONTROL at
Architect/En neer. Lk.No
QT44{, k ELEyC2'RIC PERIV IPI'" '" '4 �` FEE t ('„`. ,.B UILDINGPERMFFINFq �
e)2040ss: c s mo- �N PERMITISSUANCE ❑ . .� .•❑ � ❑, ,
LICENSED CONTRACTOR'S DECLARATION
Ihereby affurn that am licensed under provisions of Chapter9(cemmenc APPLIANCES RESIDENTIAL JOB DESCRIPTION
+ngwith Sed+on 7000)ofDlvls+on3 ofthe Busimseand Profess+onsCo le,and my -
Icenm+s+nfall fares and effed /p� PANELSUP TO 200AMPS
License`lam
Da .. Llc.p 2�T aCQ-A . V �
te Contrador 201-1000 AMPS
ARCHITECT'S DECLARATION
NOVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
'pQ±O ZpOC I understand my plan shag be usod as public records. '
Edy(0 _ Licensed Profemimtel SIGNSELECTRICAL -
GGGGa w OWNER-BUILDER DECLARATION
`IndSPECLILCIRCUIT/MISC' .
i”' Iheby atfirmthatiam axemptfromthe Contractor's License Law for the
F 'H fallorewing reason.(Sedion 7031.5,Bualrem and Protemlons Code:Any dtyor TEMP METER ORPOLE INST.
cou dywhich requlresa permittodustrod,alter,Improve,demollsh,arespa+r
anystrudure prtorteits Issuance,also requlrestheapplie nt forsuch permit to ,(pWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
3P`CConlador, kerse Pt' LLaw(Chapter (cemnpIng ncwith Section 70M)of Dlvl - VALUATION
� SWIMMING POOL ELECTRIC .
p O stun 3 of the Business and Prolamines Code)orthat he Is exempt therefrom and
q O the basis for the alleged exemption. Any violation of Section 7MI.5 by any nnreOUTLETS-SWITCHES. /�Q�
applicant for a permit subjecisthe applicant to a civil penalty of not than
five hundred dollars($500), - NEW RESIDENTIAL ELECTRSQ.Ff. TYPE CONSTRUCTION
�a ❑I,as owner of the property,or my employee,with wages as their sok
compensatlon,wWdothe work and thestmeure ls not Intended or offeredfor
qsale(Sec.7044,Business and Professions Code:The Contradots Licerse Law
does not apply to an owner of property who builds or Improve,thereon,and OCC.CROUP RFS,UNITB
who d ons such work himself w th rough his own employees,prow ided that mch
Improvereents are notlntended oroffered Tarsale.IL havever,thebuilding or TOTAL:
unprovereenteasoldwithin oneyearofcompletion,theowner-budderw+ll have }
t Men of proving that he did not bund or improve for purpose of sale.). Qyy; •,t` ;::P6UMB[NG'PT: MIT „i..}i :ti: 'EtG FLODDZONE Arlt
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
con ,s(�
tractors to ce nstrud 0
the project(Sec.7044,Business and Professions Code: 0
The Contractor',Licence Law does net apply to an owner of property who ALTERARAIN k VEM-WATER(EA)
Wild.or improve.thereon, and who centrad. for such ptajacts.wfth a ,tl 1 'FEE¢UMEYfARY't
.f
orbactor(,)licensed pursuant to the Contractors License Law. ...' +: .. .. ... i "•i'.
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,CONTE s�� SANITARY Y . N
.
.. RECEIPT N
DECLARATION
WORKMAN COMPENSATION DFIXTURES—PER TRAP SCHOOL TAX Y N
[:]I hereby affirm that I have a certificate of consort to,elf-Insure,or a 0 RECEIPT M
certificate ofWorkers'Compensation Insurance oracertlfied copythemof(Sec. GAS EA.SYSTEM-1 INC.4OUTLETS PARK FEE Y N
Polis a Lab C.) RECEIPT It
Policy
Company9 GAS EA,SYSTEM-OVER 4(EA) S.OQ ,. BUILDING DIVISION FEES
ECodified copy W hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy 6 filed with the city inspection division. r
CERTIFICATE OF EI(EMPTION FROM WORKERS' GREASE TRAP '700 PAID .
COMPENSATION INSURANCE SEWER-SANITAAY-SiDItM EA.200FT. Date Recei I#
(Thi section need nrn be complded lithe permit isforone hundred dollars
($100)or,less.) - ENERGYFEE Y N
certify WATER HEATpi W/VENT/ELECTR
I rtify that In the performance fthe work forwh+ch this permit is Issued, l
I slsll not em any person Ip,�tq ma er oo sam c u ct to the WATER SYSTEM/TREATING
Workers C Hon Law f�([�(iffyryy ate PAID
O Applicen P I�a¢sa `R ry / _SQA.. Date Recei t#
Z �' NOTICE AP LIC ILa er dngt isCertifica^ri-- to of Exemption,you
NEW RESIDENTIAL PLM..
should beceme subjoet to the Wmrkem'Compere ation provision,of the Labor TOTAL:
fA Code,you most forthwith mmplyw+th such provIs+ons or this permit shall be BUIL
DING FEE
111 j deemed decked. - - ,
CONSTRUCTION LENDING AGENCY ` SEISMIC FEE
I hereby affirm that them is a censtmction landing agency for the perform- ELECTRIC FEE
D Z TOTAL (7 O
once of the work for whkh this permit lslssued(Sec.3097,Civ.C.) )
O O lender:Name , :. PLUMBING FEE O.O
F Lender.Address - 'i:5', MtNICALPIT ',t,:'FEEcMECHANICAL - -
LL - FEE
.O W I rest. thatl Iagreatvereadywith alleftyaandstaty ordineabo edfomaaon
1 iscorrect. building
complywlth all auhombe representatives
and mate
softhilam PERMTTISSUANCE
r y citytogtobupont censluct+oryandhereby authorizepectionaof this �/ 8
F city a ree tome,indemnify
an
property for inspection ofCu Purposes. ALTER OR ADD TO MECH.
Z (VJe)agree lo'mve,Indemnity an d keep harmless the City of Cupertino Date. Re[ellst#
V agai bllitlea,pelgmenre a d expenses which may In anyway amue AIRHANDLINGUMT(TO10,000CFM) SUBTOTAL:
.ag t' CityIn con 0gra o(lMs'pe'rmit -" AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
graham of Applicart7Contrader Data E(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recta' I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)i HEATING UNIT 100,000 BTU) L:
❑Yes. �"l No - ' -
Willtheappllantorfuture building occupant use equipment or devicesVENTILATION FAN(SINGLE REBID) $$ CE T
'which emit hamedoueair contaminant.so cleaned by the Bay Area Air
Iity Management Distdd7 - BOILER-COMP(3H POR 100,000 BTU)
�i�J Yca (�N. ' :9
_ shave read the h azar us materials mquirerrend under Chapter 6.95 of ROME -COMP 100,000 BTU)
the California Health&Safety Code,Sed Ions 25505,25533 and 2:534.T, - —'�B-Tas BC�jrastay�
understand that ifthebulldieg doesnot currently have.hruirL that it is my NEWRESIDENTIALMECH. SQ.FT.
respomibillty to notify the occupant of the requimmentswhich must be met
pnorto issuance ofa Certificate of Occupancy,
Owner or authorized agent Data
TOTAL:
OFFICE COPY