21610 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldentlficadon
PERMIT NO.
Building Address:
,o��� P Dr.� 21610
errte: AFFLILAIIUN SUNM11 IAL DA 11,
�Y'r 4 F Dry 0-fg CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name LIc.Na APPLICATION / PERMIT
ff BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROLp
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..
PIRMITISSUANCE ❑ °
LICENSED CONTRACTOR'S DECLARATION
IMrcby offlim that l am licensed under provisions o(Chapter9(commen MTUANCES.RWDENTIAL JOB DESCRE ON
IngmthSection7000)of Db i,km3 ofthelbulnessandPmfenionsGde,and my
It...1.In lull force and effect. PANELS Cit-t ,�
License Clam Lic.p �-�f
Date Contactor UP TO 200
ARCHITECTS DECLARATION 201-1000 PS
7O. I understand my plans @hall he used as public recoNi OVER 1 SQ.Fr.FLOOR AREA S/SQ.FT.
6: Licensed Professional N .ECTRICA rj
�6 OWNER-BUILDER DECLARATION ICRC /
7t' � IhercbyalOnnthal]amezempt lromlhe Contractor's Llrenm Law far
qqqqqq following renor.(Section70115,Buslnessand Profx.kmn Code:Any ctty
ro0_1 countywhlch requiresa permit tocorstruct,alter,Improve,demolbh,orrepalr PM OR POId3
p�53 anystmmmpdortoltabwance,alsomquirestheappllantforsuchper tto p0
gF 6 file a signed statement that he is Ilttved pursuant to the proWiov o(.
3µ�+ Contractor.License Law(Chapter9(commendng with Settlors 7000)o(Div- ELECTRIC
VALUATION
�p uon3 ofthe Business and ProfmlonsCode)orthat he b exempt the;f'Qand ^� l
.4 the bash for the alleged exemption. Any violation of Section 70315 by any gN7TCHESHXTURFS l O W �C)
applicant fora permit subjects the appllcanl to a civil penalty of not con reton
�i
five C]1,.,reddollanhepr. RESIDENTIAL ELECT( SFT STORIES TYPE CONSTRUCTION
�L as owner will
dot property,or my employees of in wage.as sale
compensation,044,gots.. ad Prwork andthe C dei e Is Th.Cotractod License d for
Law
q dile(See 7044,to ahem and fio(mlom Code:The Commove s License Law
q$ docs not apply loan ownerofproperty gh who nemplut this yeeppr provided
that such
.
p,S., who due eeuchwork hlm.dforthrwgh hbawnemplayce.,provided thateuch OCC.CROUP RES.UNITS
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement b sold within oneyearofcompleBon,the owner-bullderwill have
trden of proving that he did not build or improve for purpose of sale.). Qry, PLUMBING PERMIT FEE FLOODZONE APN
L a@ owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
=' tr on to construct the project(Sec.7044,Ruslnm and Professions Code: Zs�
The Contractors License law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
builds or Improve thereon,and who contract@ for such ploket. with a
<gR(faee ctors)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
L�I am exempt under SB Al P C for this na.on OUTS I OF FEES
Owner Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY V N—
RFCEB f p
WORKMAN COMPENSATION DECLARATION 03 SCliQQL TAX Y N
QI hereby affirm that have a certi(lute of consent to @elf-Insure,or• FIXTURFS PER TRAP RECEIPT p
3500,Lab S
wrtlflcao(Worken'CompensaHanlnsuranre oracertified copy lhenw(($ec. GAEA.SYSTEM.1 INCA OUTLETS PARK FEE Y N
Pollry p RECEPT#
Cff"aGAS PA.SYSTEM-OVER 4(RA) BUILDING DIV
ISION PCIS
:a [Bad
copy la hereby tGREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
the
Certified copy b filed withh the cityty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANDARYSTORM EA.200FT. Date Recei tN
(T or lection need not be complctM lithe permit b(Drone hundred dollen
6100)orlyth) WATER BEATER W/VENT/ELECTR ENERGY FEE Y_ N
Trent employ
the person
ofthe work fo which a to
penult Is Ito the
I shag not employ any person In any manner m u to become cobjed to the WATER SYSTEM/TREATING
Workers'CompensaHon Laws o(GII(rrnla.Date PAID
0 Z AppilaNOTICE
OTICE NEW RESIDEI-MAL PLMB. SOFT. Date Reee1 t#
ZO NOTICEco MPLICAtothe -rite-'klngthb ti.prois Exemption,you
Ix Code,shoulyou
mus sforth forthwith
co ply with such
proatlorprovbionrmit of s Lab be - TOTAL:
Uj N Code,youvoked.nhwlth comply with such provblons rrth0 permit shall be U
IL � deemed revoked. a
MCONSTRUCTION LENDING AGENCY SEISMIC FEE
thyereba(flrmthsl there la a construction lending agency for the perform ELEC'T'RIC FEE
17 0
Z ante m(the work for which this permit if issued(Sec.3097,Civ.C.) TOTAL:
u O lander:Name PLUMBING FEE ..00
IL I— Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcertlfythatI have read lhl.appBntlonand statethatthc above lnferrnatlmn
1 19correct.I agree to complywlth all dty and county ordinances and @Rata laws PERMIT ISSUANCE FEES PAID:
T N mlating tobullding coatructlon,and herebyauthorlae re present.livnofthis
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTIRORADDIUMECH.
(We).gree to save,Indemnify a d keep harmlm the City of Cupertino Date Recei t#
against abilhies,judgments,rort@and expenan which may In anywayaccme AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
.gal Id City In con ence egrantl If this Dermic,
�' 12_ -90 AIR HANDLING UNIT(OVER I DoDoCFM) CONSTRUCTION TAX
Signa of AppB t/Comraaor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000BTU) Date Recel IN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
linithand SafetyCode Section25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: d
Yes No
a
qllltheepplinnt or future building occupant use equipment ordevlces VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardoua air contaminant as defined bythe Bay Area Air - )b ,/A B�
slily Management District? BOILER-COMP OHP OR 100,000 BTU) 1CQ^V o
Yea 9 No
have read the Fara nus materials requirement under ChapterG95 of BOILER-COMP(OVER 100,000 BM pp
the California Health h Safely Code,Sections 75505,25533 and 7:534.1 1 1' F s F�'ITA
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be mot
prior to issuance of a Certificate of Occu parry.
Owner or authorized agent Date ISSUED
TOTAL:
OFFICE COPY