21579 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Wentificalon - PERMIT NO.
Building Address: 21579
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CITY OF CUPERTINO-BUILDING DIVISION _ ��
. �aNa ur.Ne: APPLICATION /PERMIT �a��
BUR.DINGELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL N
rc teal/Fsgi er. Lie,N. -
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcca: PQ6h0TI55UANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ect1uAaffirm that lamlkm3oftheunder proasandof Cssions 9(mnmrn APPLIANCFSRESIDENITAL JOB DFSCRB'ITON
It...1 1.fun700D)of Dldeon3o(Ihe Bustmssand LarofesaloneCodsand my / ^
License Is In fu d rflect. PANELS F�QEOI
Llren lees Lk.N
Dat Cont ador �q� IT TO 200 ANTS
ARCXITECr'. DECLARATION 201-1000AMPS
pQ+mmO I understand my plans shag be used as public records. OVERIOWAMPS L ppmp--��� RAREA 5/�.Fr.
F Licensed Professional STGNSELECTRICAL yI, / tlJy R
< OWNER-BUILDER DECLARATION l yI R •
�n - SI'EC/AL GRGUIT/MISC +.
IherebyafOrm llut lam exsmpt(romthe CoNador'a License lawfor the
I Zt. following trader.(Section 7031.5,Business and Profession°Code:My city or TF3dP.METFRORPOLEINST.DATE of ,
cou my wh ich requlree a permit to me struct,alter,improve,d ernolish,or espal r
S anystmu mpdorWift smance,atsorequtr theapphantforsuchperrrdtto POWER DEVICES
25 file a signed statement that he Is licensed pursuant to the pro ilio d of the
30 Contractor's License Law(Chapur9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
1„ S slon3.fth.Buslnessand Pm(emloru CI...
.pt he empt thunfromand
the basis for the alleged exemption. Any violation of Section 70315 by any
0 appliantfor a permit subjects the applicant to a civil penalty of not rrore than OUTLETSSWTICHESFIXTURE5 �/r 9a Oct
five hundred dollars($500). SQ.FT, SID)t[IS TYPE CONSTRUCTION
.til R Ci NEW RESIDENTIAL ELECTR
(il p I,as owns of the property,or my employees with wages r offered
cele
compensation,will B.adoth°work,andthestrude: It net Intended Lioffered(or
O °ale/See 7064,euelneee and Pro(essloos Code:The ConlractaJa Wttnse Maw
docs not apply to an owner of property who build°or Imprown thereon,and
$^ who does such work himself orthrough Msownemployce,provided that such OCC.GROIIP RES,UNITS
Improvements are not intended oroffered ferule.If,however,thebuilding or TOTAL: .
Impmvermnt isadd within one yearofmmpletloq the owner-budderwlll have
tIBLkurdenofpmvmg that he did net bund or improve for purpose of ask.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
LJ m
L as owner of the property,am exclusively ntrading with Ilema d
contractors to construct the project(Sm 70K Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Maw don net apply to an owner of property who
buALTER-DRAIN A VENT-WATER(EN
Wild, or Imp eves thereon,and who contracts such p�oj -
eda with• FEE SUMMARY
�0¢�dor(°)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for this reason
DRAINS FLOOK ROOF,AREA,COND. SANITARY Y N_
. Owner Date RECEBrr p
WORKMAN COMPENSATION DECLARATION pD(TIIRES PER TRAP SCHOOL TAX Y N
1 hereby affirm that 1 have• lmume of concent to opy there,,ora RECFR'f N
Mate of Workers Compewtlonlosuranaoracertlfled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
00, abC
Polity GAS-
Q II N
Com angi r�/' GAS FA.SYSTEM-0VERd(EA) BUILDDINGNG DIVISION FEES
cert .)
ed ropy is hereby tthe cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
n Vied ropy 6(fled with the city Inspection dlvblm.
CERTIFICATE OF EXEMPTION FROM WORKERS• GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STl7RM EA 20alrr. Date Recel t#
(rhissectlon need nm be completed R the perrdt 6 forces hundred dollars
(S100)ortess.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I unify that In the performance of the work for which this permit Is issued, ,
I shall not employ any person N any runner so u to become subject to the WATER SYSTEM/TREATIN'G -
Worken'CompemationUwsof Callfomla.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMS. JJFr. Date Recei t#
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation provision of the Labor TOTAL:
CCN Code,you mud forthwith comply with such provisions or this permit shall be ,
W > deemed revoked. BUILDING
a E 119
3 CONSTRUCILON LENDING AGENCY SEISMIC FEE
)hereby affirm that there 6a commudlon bndingagenay our the perform TOTAL: ELECTRIC FEE
7 O arm ofthe work for which this permit 6issued(Sec.3097,Civ.C.) -
Lender's Name PLUMBING FEE
LL f Undsrs Addreu QTY. MECHANICAL PERMIT PEE MECHANICAL FEE
0 W Ianlfythatl havereadthisapp110ma
tionand statethattheaboveinfortion
1 boomed.l agmeto comply with all city and county ordinance and state laws PERMR :
ISSUANCE PEES PAID
N relating tobuildingmrutmdion,and herebyauthorize repreaentathio
reae(th
1•' 2 city to enter upon the above-mentioned property for liupnei purposes. ALTERORADDTOMFCH. Date Receipt#
(We)agree to save,Ind emmfy an d keep harmless the CityofCu Perim AIR HANDLING IRxTT(f010,000 CFM)
V age lost pilin,pdgments,mete a rad expense khmayin Iwaya a SUBTOTAL:
.gains I City m neaq. ofth xot ft CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
Si reo Appllant Contrado Date EXFIAusTHocoiw/Duca CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or hand he haxerdous HEATING UNIT DO 100,000 BE" Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. M No
Will the applicant cTEtuoe building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousalr contaminants asciefined bylhe Bay Area Air BOILER-COMP OFR'OR 100,000 BWQuality Management District?No
1?h I-1 No BOILER-OOMP(OVIR 100,000 BTU)
havemad the th&Sf materials requirements underChapte4. 1 of AUGthe Califodt Heathe building
Gods Sedioosntly have
ate ant that
A6
understand that if the building dose not currently have atenanL that l[6my NEW RESIDENTIAL MEIN. SQFf l7 6+
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Onto pa ncy.
Owner or authorized agent Date ISSU]UNH]D�DBY.
TOTAL
OFFICE COPY